Provider Demographics
NPI:1861745671
Name:BULLHEAD PHYSICAL THERAPY CENTER, LLC
Entity type:Organization
Organization Name:BULLHEAD PHYSICAL THERAPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:BHANU
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:928-234-1193
Mailing Address - Street 1:2767 SILVER CREEK RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-8227
Mailing Address - Country:US
Mailing Address - Phone:928-704-2194
Mailing Address - Fax:928-704-2195
Practice Address - Street 1:2767 SILVER CREEK RD
Practice Address - Street 2:SUITE B
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-8227
Practice Address - Country:US
Practice Address - Phone:928-704-2194
Practice Address - Fax:928-704-2195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5387261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy