Healthcare Provider Details

I. General information

NPI: 1225361074
Provider Name (Legal Business Name): PHOENIX CONQUEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2009
Last Update Date: 09/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 ADAMS POINTE BLVD SUITE #6
MARS PA
16046-4667
US

IV. Provider business mailing address

PO BOX 844
MARS PA
16046-0844
US

V. Phone/Fax

Practice location:
  • Phone: 412-302-1668
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. MARK WATSON
Title or Position: CEO
Credential: P.T.
Phone: 412-302-1668