Basic Information
| Provider Information | |||||||||
| NPI: | 1891706784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEMONBREUN | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3559 S DESERT MOTIF RD | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857355158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5204908751 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3601 S 6TH AVE | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857230001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207921450 | ||||||||
| FaxNumber: | 5206294621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 05/30/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 2567 | AZ | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 2567 | 01 | AZ | PT LICENSE NUMBER | OTHER |