Provider Demographics
NPI:1124497540
Name:IDEAL MOTION PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:IDEAL MOTION PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:907-694-5515
Mailing Address - Street 1:12551 OLD GLENN HWY STE E
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7590
Mailing Address - Country:US
Mailing Address - Phone:907-694-5515
Mailing Address - Fax:907-694-5575
Practice Address - Street 1:12551 OLD GLENN HWY STE E
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7590
Practice Address - Country:US
Practice Address - Phone:907-694-5515
Practice Address - Fax:907-694-5575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-15
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1021707261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1029575Medicaid