Provider Demographics
NPI:1558587683
Name:KIDS INSTRUCTION FOR DEVELOPMENTAL SERVICES, LLC
Entity Type:Organization
Organization Name:KIDS INSTRUCTION FOR DEVELOPMENTAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:LANGENBACH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:602-380-6761
Mailing Address - Street 1:726 W AIRE LIBRE AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85023-7910
Mailing Address - Country:US
Mailing Address - Phone:602-380-6761
Mailing Address - Fax:602-938-9839
Practice Address - Street 1:726 W AIRE LIBRE AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-7910
Practice Address - Country:US
Practice Address - Phone:602-380-6761
Practice Address - Fax:602-938-9839
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ18292251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ187240Medicaid