MEDICARE: MS. DINIWE PETER RPT

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	5501011672	MI

General Provider Information

NPI Number	:	1760568042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DINIWE PETER RPT

Provider Business Mailing Address
First Line	:	1001 MEDICAL PARK DR SE
Second Line	:	SUITE 111
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-3610
Country	:	US
Telephone Number	:	616-957-4014
Fax Number	:	616-956-0059

Provider Business Practice Location Address
First Line	:	1001 MEDICAL PARK DR SE
Second Line	:	SUITE 111
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-3610
Country	:	US
Telephone Number	:	616-957-4014
Fax Number	:	616-956-0059

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

Provider Enumeration Date	:	10/28/2006
Last Update Date	:	07/08/2007

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