Provider Demographics
NPI:1912175001
Name:IDEAL REHABILITATION PLLC
Entity Type:Organization
Organization Name:IDEAL REHABILITATION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRAUNING
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, ATC, MTC
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 1:805 N DOBSON RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-7661
Practice Address - Country:US
Practice Address - Phone:480-222-0655
Practice Address - Fax:480-222-1457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ321756Medicaid
AZ128769Medicare PIN