Healthcare Provider Details

I. General information

NPI: 1003203605
Provider Name (Legal Business Name): THUNDER BAY THERAPY & SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 04/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

348 LONG RAPIDS PLZ
ALPENA MI
49707-1374
US

IV. Provider business mailing address

6511 OSAGE AVE
ALLEN PARK MI
48101-2371
US

V. Phone/Fax

Practice location:
  • Phone: 989-358-8086
  • Fax: 989-354-2253
Mailing address:
  • Phone: 313-282-9304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number5201009050
License Number StateMI

VIII. Authorized Official

Name: MISS KRISTINE ERNST
Title or Position: OCCUPATIONAL THERAPIST
Credential: OTRL
Phone: 313-282-9304