Provider Demographics
NPI:1215319462
Name:REATHERFORD, CT
Entity type:Individual
Prefix:
First Name:CT
Middle Name:
Last Name:REATHERFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3771 E CAROL LN
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-5679
Mailing Address - Country:US
Mailing Address - Phone:602-309-4158
Mailing Address - Fax:
Practice Address - Street 1:3771 E CAROL LN
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-5679
Practice Address - Country:US
Practice Address - Phone:602-309-4158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-20747172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist