Provider Demographics
NPI:1124176342
Name:SOUTH MOUNTAIN REHABILITATION P.C.
Entity type:Organization
Organization Name:SOUTH MOUNTAIN REHABILITATION P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:VINCENT
Authorized Official - Last Name:PAKULIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC,PT
Authorized Official - Phone:480-759-1082
Mailing Address - Street 1:16016 S 45TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-7635
Mailing Address - Country:US
Mailing Address - Phone:480-759-1082
Mailing Address - Fax:480-785-5161
Practice Address - Street 1:4804 E CHANDLER BLVD
Practice Address - Street 2:106
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0857
Practice Address - Country:US
Practice Address - Phone:480-893-6020
Practice Address - Fax:480-785-5161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-05
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2853225100000X
AZ5302111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAZ0241550OtherBCBS CHIROPRACTIC #
AZAZ0295410OtherBCBS PHYSICAL THERAPY #
AZAZ0241550OtherBCBS CHIROPRACTIC #
AZZ67951Medicare ID - Type UnspecifiedMEDICARE CHIROPRACTIC #