Healthcare Provider Details

I. General information

NPI: 1043225717
Provider Name (Legal Business Name): MICHAEL RONALD HUYLEBROECK P.T.. M.B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 WEST HOSPITAL DRIVE
WHITERIVER AZ
85941
US

IV. Provider business mailing address

6578 PINTO CIR
PINETOP AZ
85935-8217
US

V. Phone/Fax

Practice location:
  • Phone: 928-338-3611
  • Fax:
Mailing address:
  • Phone: 928-338-3611
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1803
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: