MEDICARE: VIVIAN M PACE MPT

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	2149	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790887255
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIVIAN M PACE MPT

Provider Business Mailing Address
First Line	:	PO BOX 3748
Second Line	:
City	:	CAMP VERDE
State	:	AZ
Zip	:	86322-3748
Country	:	US
Telephone Number	:	928-567-0987
Fax Number	:	928-567-5562

Provider Business Practice Location Address
First Line	:	522 W FINNIE FLATS RD STE D
Second Line	:
City	:	CAMP VERDE
State	:	AZ
Zip	:	86322-7265
Country	:	US
Telephone Number	:	928-567-0987
Fax Number	:	928-567-5562

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/03/2006
Last Update Date	:	07/08/2007

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Directions to “ VIVIAN M PACE MPT” Practice Location

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