Black Ridge Physical Therapy, PLC

Primary specialty

Physical Therapy Clinic/CenterTaxonomy code 261QP2000X

License

8544 Issued in AZ

Legal business name

BLACK RIDGE PHYSICAL THERAPY, PLC

Practice address

80 S 13TH West
Saint Johns, AZ 85936

Phone

(928) 337-3020

Fax

(928) 337-3979

NPI assigned

Apr 3, 2014

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Carl S Wiltbank, DPTNPI 1699903757

Title

Owner

Phone

(928) 337-3020

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Enrolled in AZ

Enrollment records 1

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Carl S Wiltbank, DPT

  • Physical Therapist
  • St. Johns, AZ
  • NPI 1699903757
  Medicare reassignment NPD Authorized official
• Brittany Gray, PTA

  • Physical Therapy Assistant
  • St. Johns, AZ
  • NPI 1487103297
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1396483200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1402876800000",
    "number": "1649698945",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 824",
            "city": "SAINT JOHNS",
            "state": "AZ",
            "postal_code": "859360824",
            "telephone_number": "928-337-3020",
            "fax_number": "928-337-3979"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "80 S 13TH WEST",
            "city": "SAINT JOHNS",
            "state": "AZ",
            "postal_code": "85936",
            "telephone_number": "928-337-3020",
            "fax_number": "928-337-3979"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLACK RIDGE PHYSICAL THERAPY, PLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-04-03",
        "last_updated": "2014-06-16",
        "status": "A",
        "authorized_official_last_name": "WILTBANK",
        "authorized_official_first_name": "CARL",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "928-337-3020",
        "authorized_official_credential": "DPT"
    },
    "taxonomies": [
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": "AZ",
            "license": "8544",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "443777",
            "state": "AZ"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE",
            "identifier": "Z131189",
            "state": "AZ"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• April Marie Allen
• Apache County Public Health Services
• Richie Patterson Bast, M.D.
• Jenne K Brdlik, LMSW
• Frances Marie Buttrey, M.ED. ,SLPL
• City of St.Johns
• Clever Transit LLC
• Harry Shelton Cole Jr., LMFT

• Physical Therapy Clinic/Center in Saint Johns, AZ
• Providers in Saint Johns, AZ by specialty
• Physical Therapy Clinic/Center in Arizona

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 16, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.