Healthcare Provider Details

I. General information

NPI: 1710991674
Provider Name (Legal Business Name): RICHARD ALAN FRUITMAN MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 06/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42955 FORD RD
CANTON MI
48187-3308
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 734-981-2100
  • Fax: 734-981-2622
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501010181
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: