MEDICARE: HAVASU PHYSICAL THERAPY

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
1	225100000X	Physical Therapist	2169	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2169	OTHER	AZ	AZ BOARD OF PT EXAMINERS
2	5372	OTHER	CA	PT BOARD OF CA

General Provider Information

NPI Number	:	1134111529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HAVASU PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	2126 MCCULLOCH BLVD N
Second Line	:	STE 18
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6742
Country	:	US
Telephone Number	:	928-854-7676
Fax Number	:	928-854-7676

Provider Business Practice Location Address
First Line	:	2126 MCCULLOCH BLVD N
Second Line	:	STE 18
City	:	LAKE HAVASU CITY
State	:	AZ
Zip	:	86403-6742
Country	:	US
Telephone Number	:	928-854-7676
Fax Number	:	928-854-7676

Authorized Official
Title or Position	:	OWNER / SOLE PROPRIETOR
Name	:	MRS. DONNA GALE JONES
Credential	:	PT
Telephone Number	:	928-854-7676

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	08/22/2020

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Directions to “HAVASU PHYSICAL THERAPY ” Practice Location

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