MEDICARE: FUNCTIONAL PHYSICAL THERAPY OF CLARKSTON

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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1417079187
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTIONAL PHYSICAL THERAPY OF CLARKSTON

Provider Business Mailing Address
First Line	:	4206 PONTIAC LAKE RD
Second Line	:
City	:	WATERFORD
State	:	MI
Zip	:	48328-1261
Country	:	US
Telephone Number	:	248-673-6980
Fax Number	:	248-673-7497

Provider Business Practice Location Address
First Line	:	7736 ORTONVILLE RD STE C
Second Line	:
City	:	CLARKSTON
State	:	MI
Zip	:	48348-4483
Country	:	US
Telephone Number	:	248-620-1415
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	KORNELIS OOSTHEK
Credential	:	PT
Telephone Number	:	248-620-1415

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	08/22/2020

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