=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528145331
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. JAMES MICHAEL RETTLER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 N US HIGHWAY 89
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86313-5001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-455-4860
-----------------------------------------------------
Fax | 928-776-6172
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1955 W ROCK CASTLE DR
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86305-2110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-830-9045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 226300000X
-----------------------------------------------------
Taxonomy Name | Kinesiotherapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------