Provider Demographics
NPI:1114202546
Name:REALES, RONALD (PT)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:REALES
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6616 N 160TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68116-4071
Mailing Address - Country:US
Mailing Address - Phone:402-492-2662
Mailing Address - Fax:402-492-2662
Practice Address - Street 1:7 ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-0239
Practice Address - Country:US
Practice Address - Phone:712-328-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA03052225100000X
NE1187225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist