=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134632342
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KERNAN MANUAL PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2017
-----------------------------------------------------
Last Update Date | 11/09/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3819 E INDIAN SCHOOL RD
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85018-5234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-524-0536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 332 E PIERCE ST
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85281-1041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-524-0536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST/OWNER
-----------------------------------------------------
Name | DANA JEAN KELLY KERNAN
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 480-524-0536
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 6280
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------