MEDICARE: BLACK CANYON PHYSICAL THERAPY, PLLC

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	261QP2000X	Physical Therapy Clinic/Center	3297	AZ

General Provider Information

NPI Number	:	1134679814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLACK CANYON PHYSICAL THERAPY, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 1515
Second Line	:
City	:	BLACK CANYON CITY
State	:	AZ
Zip	:	85324-1515
Country	:	US
Telephone Number	:	623-363-8691
Fax Number	:	928-212-8727

Provider Business Practice Location Address
First Line	:	34301 S OLD BLACK CANYON HWY STE 7
Second Line	:
City	:	BLACK CANYON CITY
State	:	AZ
Zip	:	85324-9728
Country	:	US
Telephone Number	:	623-363-8691
Fax Number	:	928-212-8727

Authorized Official
Title or Position	:	MEMBER
Name	:	MR. GREGG POTTER
Credential	:	PT
Telephone Number	:	623-363-8691

Provider Enumeration Date	:	10/06/2016
Last Update Date	:	02/05/2017

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