MEDICARE: KIDS INSTRUCTION FOR DEVELOPMENTAL SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251P0200X	Pediatric Physical Therapist	1829	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558587683
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS INSTRUCTION FOR DEVELOPMENTAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	726 W AIRE LIBRE AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85023-7910
Country	:	US
Telephone Number	:	602-380-6761
Fax Number	:	602-938-9839

Provider Business Practice Location Address
First Line	:	726 W AIRE LIBRE AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85023-7910
Country	:	US
Telephone Number	:	602-380-6761
Fax Number	:	602-938-9839

Authorized Official
Title or Position	:	OWNER
Name	:	JEANINE TERESA LANGENBACH
Credential	:	P.T.
Telephone Number	:	602-380-6761

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	06/11/2008

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