=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093971566
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FORT MOHAVE PHYSICAL THERAPY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2008
-----------------------------------------------------
Last Update Date | 08/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5902 S HIGHWAY 95 SUITE 102
-----------------------------------------------------
City | FORT MOHAVE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86426-6078
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-577-0336
-----------------------------------------------------
Fax | 928-577-0337
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1750 HIGHWAY 95 SUITE 3
-----------------------------------------------------
City | BULLHEAD CITY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86442-6978
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-577-0336
-----------------------------------------------------
Fax | 928-577-0337
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. BEA MONTGOMERY
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 928-577-0336
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------