MEDICARE: PHYSIO MATRIX INC.

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	5501012446	MI

General Provider Information

NPI Number	:	1548275993
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSIO MATRIX INC.

Provider Business Mailing Address
First Line	:	15841 W WARREN AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48228-3737
Country	:	US
Telephone Number	:	313-846-9250
Fax Number	:	313-846-9325

Provider Business Practice Location Address
First Line	:	15841 W WARREN AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48228-3737
Country	:	US
Telephone Number	:	313-846-9250
Fax Number	:	313-846-9325

Authorized Official
Title or Position	:	PRESIDENT
Name	:	NAIM M KHANAFER
Credential	:
Telephone Number	:	313-846-9250

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	12/03/2007

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Directions to “PHYSIO MATRIX INC. ” Practice Location

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