Provider Demographics
NPI:1598188096
Name:ADVANCED NEUROLOGIC REHABILITATION
Entity type:Organization
Organization Name:ADVANCED NEUROLOGIC REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFERSON
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:480-244-7011
Mailing Address - Street 1:4180 S AMBROSIA DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-4804
Mailing Address - Country:US
Mailing Address - Phone:480-244-7011
Mailing Address - Fax:
Practice Address - Street 1:4180 S AMBROSIA DR
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85248-4804
Practice Address - Country:US
Practice Address - Phone:480-244-7011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-04
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9343261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy