MEDICARE: COLORADO RIVER PHYSICAL THERAPY LLC

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
2	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1245965342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COLORADO RIVER PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	1510 E WAGON WHEEL LN STE 110
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6698
Country	:	US
Telephone Number	:	928-248-0444
Fax Number	:

Provider Business Practice Location Address
First Line	:	1510 E WAGON WHEEL LN
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6697
Country	:	US
Telephone Number	:	928-788-3333
Fax Number	:	928-788-3555

Authorized Official
Title or Position	:	PHYSICAL THERAPIST/ OFFICER
Name	:	HANZ TABORA
Credential	:	PT,DPT
Telephone Number	:	928-248-0444

Provider Enumeration Date	:	07/21/2022
Last Update Date	:	09/29/2023

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