Healthcare Provider Details

I. General information

NPI: 1164552337
Provider Name (Legal Business Name): CHARLENE VANDRIL SWAIN P.T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8450 N 43RD ST
AUGUSTA MI
49012-9651
US

IV. Provider business mailing address

73 S LAKE DOSTER DR
PLAINWELL MI
49080-9109
US

V. Phone/Fax

Practice location:
  • Phone: 269-731-4471
  • Fax: 269-731-2990
Mailing address:
  • Phone: 269-664-4022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501005239
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: