Healthcare Provider Details

I. General information

NPI: 1386173110
Provider Name (Legal Business Name): KEVIN C KLEISLER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 06/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W ELLIOT RD STE 104
TEMPE AZ
85284-1373
US

IV. Provider business mailing address

15410 S MOUNTAIN PKWY STE 112
PHOENIX AZ
85044-6691
US

V. Phone/Fax

Practice location:
  • Phone: 480-756-8617
  • Fax: 480-820-9909
Mailing address:
  • Phone: 480-706-1161
  • Fax: 480-706-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13061
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: