MEDICARE: ANGEL MARIE VANCE P.T.A

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	225200000X	Physical Therapy Assistant	04870	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	04870	OTHER	OH	OHIO PHYSICAL THERAPY

General Provider Information

NPI Number	:	1215139050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGEL MARIE VANCE P.T.A

Provider Business Mailing Address
First Line	:	19977 HUDSON BAY
Second Line	:
City	:	CLINTON TWP
State	:	MI
Zip	:	48038-1493
Country	:	US
Telephone Number	:	586-416-1990
Fax Number	:

Provider Business Practice Location Address
First Line	:	1331 TRUMBULL ST STE 100
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48216-1376
Country	:	US
Telephone Number	:	313-962-9050
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	07/08/2007

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