MEDICARE: METAMORA PHYSICAL THERAPY LLC

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	261QP2000X	Physical Therapy Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1295805984	OTHER		NPI
2	1497798326	OTHER		NPI

General Provider Information

NPI Number	:	1396257135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METAMORA PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	3562 S LAPEER RD STE F
Second Line	:
City	:	METAMORA
State	:	MI
Zip	:	48455-8998
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3562 S LAPEER RD STE F
Second Line	:
City	:	METAMORA
State	:	MI
Zip	:	48455-8998
Country	:	US
Telephone Number	:	810-212-1277
Fax Number	:

Authorized Official
Title or Position	:	DPT
Name	:	HEIDI IRWIN
Credential	:
Telephone Number	:	810-964-3125

Provider Enumeration Date	:	11/02/2017
Last Update Date	:	12/21/2017

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