Provider Demographics
NPI:1699148742
Name:FOUNTAIN HILLS PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:FOUNTAIN HILLS PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GREENSTREET
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-404-6775
Mailing Address - Street 1:1820 E RAY RD
Mailing Address - Street 2:SUITE A204
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-8720
Mailing Address - Country:US
Mailing Address - Phone:480-264-5154
Mailing Address - Fax:480-264-0675
Practice Address - Street 1:16650 E PALISADES BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:FOUNTAIN HILLS
Practice Address - State:AZ
Practice Address - Zip Code:85268-3764
Practice Address - Country:US
Practice Address - Phone:480-404-6775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-10
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5470225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty