Provider Demographics
NPI:1215169677
Name:IDEAL REHABILITATION PLLC
Entity type:Organization
Organization Name:IDEAL REHABILITATION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:FRITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-222-0655
Mailing Address - Street 1:PO BOX 269084
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-9084
Mailing Address - Country:US
Mailing Address - Phone:480-222-0655
Mailing Address - Fax:480-222-1457
Practice Address - Street 1:7558 W THUNDERBIRD RD
Practice Address - Street 2:SUITE 1 PMB 408
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-6080
Practice Address - Country:US
Practice Address - Phone:623-398-8072
Practice Address - Fax:480-222-1457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-19
Last Update Date:2009-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ111768Medicare PIN