Healthcare Provider Details

I. General information

NPI: 1073610440
Provider Name (Legal Business Name): NORTHWEST ORTHOPEDIC & SPORTS PHYSICAL THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13540 W CAMINO DEL SOL STE 6
SUN CITY WEST AZ
85375-4435
US

IV. Provider business mailing address

13540 W CAMINO DEL SOL STE 6
SUN CITY WEST AZ
85375-4435
US

V. Phone/Fax

Practice location:
  • Phone: 623-556-5013
  • Fax: 480-508-5894
Mailing address:
  • Phone: 623-556-5013
  • Fax: 480-508-5894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateAZ

VIII. Authorized Official

Name: LACY LA' NETTE WYSOPAL
Title or Position: MANAGING MEMBER
Credential:
Phone: 623-556-5013