Provider Demographics
NPI:1043225717
Name:HUYLEBROECK, MICHAEL RONALD (PT MBA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RONALD
Last Name:HUYLEBROECK
Suffix:
Gender:M
Credentials:PT MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6578 PINTO CIR
Mailing Address - Street 2:
Mailing Address - City:PINETOP
Mailing Address - State:AZ
Mailing Address - Zip Code:85935-8217
Mailing Address - Country:US
Mailing Address - Phone:928-338-3611
Mailing Address - Fax:
Practice Address - Street 1:200 WEST HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:WHITERIVER
Practice Address - State:AZ
Practice Address - Zip Code:85941
Practice Address - Country:US
Practice Address - Phone:928-338-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1803225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8HC886Medicare ID - Type UnspecifiedCBQ
AZ8HC885Medicare ID - Type UnspecifiedWHITERIVER