NPIMap

Organization Active NPI

Canyon Physical Therapy and Aquatic Rehabilitation, P.L.L.C.

  • Physical Therapy Clinic/Center
  • Prescott Valley, AZ
National Provider Identifier
1831149913
Registry record updated Jul 10, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physical Therapy Clinic/CenterTaxonomy code 261QP2000X
Legal business name
CANYON PHYSICAL THERAPY AND AQUATIC REHABILITATION, P.L.L.C.
Practice address
2852 N Navajo Dr
Suite a
Prescott Valley, AZ 86314-4963
Phone
(928) 772-9797
Fax
(928) 772-9340
NPI assigned
May 11, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 10, 2024

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

Authorized official

Name
Mr. Kelly Gerrit Vredeveld, D.P.T.NPI 1588602874
Title
Manager
Phone
(928) 772-9797

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physical Therapy Clinic/Center 261QP2000X Primary

Addresses

Primary practice location

2852 N Navajo Dr
Suite a
Prescott Valley, AZ 86314-4963

Mailing address

2852 N Navajo Dr
Suite a
Prescott Valley, AZ 86314-4963
Phone (928) 772-9797

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20060628000088 AZ Part B Supplier - Clinic/Group Practice 0749292258 Receives reassigned benefits from 4 practitioners
Practice locations: Prescott Valley, AZ

National Provider Directory

National Provider Directory

Locations

2852 N Navajo Dr
Ste A
Prescott Vly, AZ 86314
Phone (928) 772-9797

Practitioners & affiliated clinicians

Practitioners 11

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1147305600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1720569600000",
    "number": "1831149913",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2852 N NAVAJO DR",
            "address_2": "SUITE A",
            "city": "PRESCOTT VALLEY",
            "state": "AZ",
            "postal_code": "863144963",
            "telephone_number": "928-772-9797",
            "fax_number": "928-772-9340"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2852 N NAVAJO DR",
            "address_2": "SUITE A",
            "city": "PRESCOTT VALLEY",
            "state": "AZ",
            "postal_code": "863144963",
            "telephone_number": "928-772-9797",
            "fax_number": "928-772-9340"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CANYON PHYSICAL THERAPY AND AQUATIC REHABILITATION, P.L.L.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-05-11",
        "last_updated": "2024-07-10",
        "certification_date": "2024-07-10",
        "status": "A",
        "authorized_official_last_name": "VREDEVELD",
        "authorized_official_first_name": "KELLY",
        "authorized_official_middle_name": "GERRIT",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "928-772-9797",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "D.P.T."
    },
    "taxonomies": [
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Prescott Valley, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 10, 2024; 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.