=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518422054
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PM&R OF YUMA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2019
-----------------------------------------------------
Last Update Date | 07/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1773 W 24TH ST STE C
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-6230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-955-0002
-----------------------------------------------------
Fax | 844-260-2871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1773 W 24TH ST STE C
-----------------------------------------------------
City | YUMA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85364-6230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-955-0002
-----------------------------------------------------
Fax | 844-260-2871
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | HELEN OLLER
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 928-955-0002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0401X
-----------------------------------------------------
Taxonomy Name | Comprehensive Outpatient Rehabilitation Facility (CORF)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------