=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538982061
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACOB DALTON PISTOL MILLS PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21576 S ELLSWORTH LOOP RD STE 108
-----------------------------------------------------
City | QUEEN CREEK
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85142-1068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-737-2275
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 552 W LOVE RD
-----------------------------------------------------
City | SAN TAN VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85143-4808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-694-2245
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 014294
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------