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NPI Code Detail

MEDICARE: DEREK R FLAKE PT

MEDICARE: DEREK R FLAKE PT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist8520PTAZ

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
18520PTOTHERAZARIZONA PT LICENSE

General Provider Information

NPI Number : 1104154269
Entity Type Code : Individual
Provider Name (Legal Business Name) : DEREK R FLAKE PT
Provider Business Mailing Address
First Line : PO BOX 1420
Second Line :
City : SHOW LOW
State : AZ
Zip : 85902-1420
Country : US
Telephone Number : 928-532-1221
Fax Number : 928-532-1227
Provider Business Practice Location Address
First Line : 4830 HIGHWAY 260 STE 105
Second Line :
City : LAKESIDE
State : AZ
Zip : 85929-5851
Country : US
Telephone Number : 928-532-1221
Fax Number : 928-532-1227
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/01/2009
Last Update Date : 03/16/2020

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Directions to “ DEREK R FLAKE PT” Practice Location

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