=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871559658
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THERASPORT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2006
-----------------------------------------------------
Last Update Date | 10/27/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15950 N 76TH ST SUITE 105
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-1882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-596-3371
-----------------------------------------------------
Fax | 480-596-3849
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15950 N 76TH ST SUITE 105
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-1882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-596-3371
-----------------------------------------------------
Fax | 480-596-3849
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER DIRECTOR
-----------------------------------------------------
Name | MR. WILLIAM C. BROWN
-----------------------------------------------------
Credential | P.T
-----------------------------------------------------
Telephone | 480-596-3371
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------