Healthcare Provider Details

I. General information

NPI: 1477005254
Provider Name (Legal Business Name): DONALD ANDERSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 JACKSON RD STE D
ANN ARBOR MI
48103-1867
US

IV. Provider business mailing address

5060 JACKSON RD STE D
ANN ARBOR MI
48103-1867
US

V. Phone/Fax

Practice location:
  • Phone: 734-627-8001
  • Fax: 734-433-1989
Mailing address:
  • Phone: 734-635-7187
  • Fax: 734-433-1989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004901
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number75010003128
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: