Organization
BLACK RIDGE PHYSICAL THERAPY, PLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CARL S WILTBANK DPT (OWNER)
(928) 337-3020
Entity
Organization
Contact information
Practice address
80 S 13TH WEST, SAINT JOHNS, AZ 85936
(928) 337-3020
(928) 337-3979
Mailing address
PO BOX 824, SAINT JOHNS, AZ 85936-0824
(928) 337-3020
(928) 337-3979
Taxonomy
Speciality
Code
Description
License number
State
261QP2000X
Physical Therapy Clinic/Center
Primary
8544
AZ
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
443777
—
AZ
01
—
Z131189
MEDICARE
AZ
Enumeration date
04/03/2014
Last updated
06/16/2014
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