Healthcare Provider Details

I. General information

NPI: 1083811749
Provider Name (Legal Business Name): MARK S DECARLO PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 04/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12955 OLD MERIDIAN ST STE 101
CARMEL IN
46032-7100
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 317-819-6600
  • Fax: 317-819-6601
Mailing address:
  • Phone: 586-350-2644
  • Fax: 586-541-3735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number050018551
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: