Provider Demographics
NPI:1477913127
Name:IDEAL PHYSICAL THERAPY SERVICES,INC
Entity Type:Organization
Organization Name:IDEAL PHYSICAL THERAPY SERVICES,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAZEEM
Authorized Official - Middle Name:A
Authorized Official - Last Name:AGBOOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-659-6847
Mailing Address - Street 1:PO BOX 99037
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-9037
Mailing Address - Country:US
Mailing Address - Phone:313-659-6847
Mailing Address - Fax:313-659-6867
Practice Address - Street 1:14058 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3928
Practice Address - Country:US
Practice Address - Phone:313-659-6847
Practice Address - Fax:313-659-6867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-23
Last Update Date:2016-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI550010067942251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty