MEDICARE: 360 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	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1841712908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	360 PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	1076 W CHANDLER BLVD STE 103
Second Line	:
City	:	CHANDLER
State	:	AZ
Zip	:	85224-5223
Country	:	US
Telephone Number	:	480-821-1997
Fax Number	:	480-782-5213

Provider Business Practice Location Address
First Line	:	6630 W CACTUS RD STE B112
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85304-1662
Country	:	US
Telephone Number	:	480-821-1997
Fax Number	:	480-782-5213

Authorized Official
Title or Position	:	VP OF BILLING OPERATIONS
Name	:	CHERYL BRUNIN
Credential	:
Telephone Number	:	480-821-1997

Provider Enumeration Date	:	07/11/2017
Last Update Date	:	06/16/2018

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