Provider Demographics
NPI:1215923677
Name:DIAMONDBACK PHYSICAL THERAPY
Entity type:Organization
Organization Name:DIAMONDBACK PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAINEY
Authorized Official - Middle Name:H
Authorized Official - Last Name:GARRRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-632-6667
Mailing Address - Street 1:323 S GILBERT RD
Mailing Address - Street 2:SUITE # 115
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-1602
Mailing Address - Country:US
Mailing Address - Phone:480-632-6667
Mailing Address - Fax:480-632-6668
Practice Address - Street 1:323 S GILBERT RD
Practice Address - Street 2:SUITE # 115
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-1602
Practice Address - Country:US
Practice Address - Phone:480-632-6667
Practice Address - Fax:480-632-6668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ484444Medicaid
AZZ29485Medicare PIN