Healthcare Provider Details

I. General information

NPI: 1700010154
Provider Name (Legal Business Name): JAGGED ROCK REHAB TRAVELERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 05/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10667 S AVENUE 10 E # 46
YUMA AZ
85365-7008
US

IV. Provider business mailing address

10667 S AVENUE 10 E # 46
YUMA AZ
85365-7008
US

V. Phone/Fax

Practice location:
  • Phone: 605-430-9361
  • Fax:
Mailing address:
  • Phone: 605-430-9361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberDDD704011
License Number StateAZ

VIII. Authorized Official

Name: MONIKA SHUMBOPOISSANT
Title or Position: OWNER
Credential: OTR
Phone: 605-430-9361