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General NPI Number Information
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NPI Number | 1629623657
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Entity Type | Individual
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Provider Name | JORDAN CRAIG RIBOTA PT, DPT
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Gender | Male
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Dates
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Enumeration Date | 08/06/2019
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Last Update Date | 09/16/2024
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Provider Practice Location Address
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Address Line | 825 S WATSON RD STE 106
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City | BUCKEYE
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State | AZ
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Zip | 85326-3435
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Country | US
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Telephone | 623-207-4015
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Fax | 623-471-8746
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Provider Business Mailing Address
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Address Line | 790 REMINGTON BLVD
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City | BOLINGBROOK
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State | IL
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Zip | 60440-4909
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Country | US
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Telephone |
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Fax |
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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 | 30810
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License Number State | AZ
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