Healthcare Provider Details

I. General information

NPI: 1598966764
Provider Name (Legal Business Name): PROSTAFF PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7609 BROCKWAY RD
BROCKWAY MI
48097-3459
US

IV. Provider business mailing address

7609 BROCKWAY RD
BROCKWAY MI
48097-3459
US

V. Phone/Fax

Practice location:
  • Phone: 810-387-4900
  • Fax: 810-387-9200
Mailing address:
  • Phone: 810-387-4900
  • Fax: 810-387-9200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5501008034
License Number StateMI

VIII. Authorized Official

Name: TIMOTHY D VINCENT
Title or Position: OWNER
Credential: MPT
Phone: 810-387-4900