Provider Demographics
NPI:1902138431
Name:COREPHYSIO LLC
Entity Type:Organization
Organization Name:COREPHYSIO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:RAOUL
Authorized Official - Last Name:REEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:480-507-0130
Mailing Address - Street 1:1017 S GILBERT RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85204-4442
Mailing Address - Country:US
Mailing Address - Phone:480-507-0130
Mailing Address - Fax:480-507-0135
Practice Address - Street 1:1017 S GILBERT RD
Practice Address - Street 2:SUITE 104
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-4442
Practice Address - Country:US
Practice Address - Phone:480-507-0130
Practice Address - Fax:480-507-0135
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-09
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6440225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1114905254OtherNPI