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General NPI Number Information
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NPI Number | 1104154269
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Entity Type | Individual
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Provider Name | DEREK R FLAKE PT
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Gender | Male
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Dates
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Enumeration Date | 12/01/2009
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Last Update Date | 03/16/2020
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Provider Practice Location Address
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Address Line | 4830 HIGHWAY 260 STE 105
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City | LAKESIDE
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State | AZ
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Zip | 85929-5851
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Country | US
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Telephone | 928-532-1221
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Fax | 928-532-1227
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Provider Business Mailing Address
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Address Line | PO BOX 1420
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City | SHOW LOW
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State | AZ
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Zip | 85902-1420
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Country | US
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Telephone | 928-532-1221
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Fax | 928-532-1227
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 8520PT
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License Number State | AZ
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