Healthcare Provider Details

I. General information

NPI: 1659675346
Provider Name (Legal Business Name): NATHAN MICHAEL BENJAMIN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 S CENTER RD STE 12
BURTON MI
48509-1700
US

IV. Provider business mailing address

7601 LIONS GATE PKWY
DAVISON MI
48423-3195
US

V. Phone/Fax

Practice location:
  • Phone: 810-743-8820
  • Fax: 810-743-5908
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5502003080
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: