Healthcare Provider Details

I. General information

NPI: 1265521702
Provider Name (Legal Business Name): ADEBOLA ADEKANMBI PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8433 N BLACK CANYON HWY
PHOENIX AZ
85021-4873
US

IV. Provider business mailing address

PO BOX 39717
PHOENIX AZ
85069-9717
US

V. Phone/Fax

Practice location:
  • Phone: 623-939-3112
  • Fax: 623-939-3106
Mailing address:
  • Phone: 623-939-3112
  • Fax: 623-939-3106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3951
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number3951
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number3951
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number3951
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: