Healthcare Provider Details

I. General information

NPI: 1275891756
Provider Name (Legal Business Name): ARIZONA ACTIVE AGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10440 E RIGGS RD SUITE 120
SUN LAKES AZ
85248-7751
US

IV. Provider business mailing address

10440 E RIGGS RD SUITE 120
SUN LAKES AZ
85248-7751
US

V. Phone/Fax

Practice location:
  • Phone: 480-361-2217
  • Fax: 480-664-4223
Mailing address:
  • Phone: 480-361-2217
  • Fax: 480-664-4223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateAZ

VIII. Authorized Official

Name: PETER CHARLES WEIDNER
Title or Position: OWNER
Credential:
Phone: 480-361-2217