=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649291584
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROGER SURETTE PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2006
-----------------------------------------------------
Last Update Date | 05/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 EL CAMINO REAL STE 10G
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85635-2825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-458-5105
-----------------------------------------------------
Fax | 520-459-2357
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 302 EL CAMINO REAL STE 10G
-----------------------------------------------------
City | SIERRA VISTA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85635-2825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-458-5105
-----------------------------------------------------
Fax | 520-459-2357
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTRACTS
-----------------------------------------------------
Name | SANDY KAPLAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 520-458-6331
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1091
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------