Healthcare Provider Details

I. General information

NPI: 1154073690
Provider Name (Legal Business Name): XPERIENCE PHYSICAL THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2022
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1352 US HIGHWAY 2
CRYSTAL FALLS MI
49920-1047
US

IV. Provider business mailing address

1352 US HIGHWAY 2
CRYSTAL FALLS MI
49920-1047
US

V. Phone/Fax

Practice location:
  • Phone: 906-874-1124
  • Fax: 906-874-2124
Mailing address:
  • Phone: 906-874-1124
  • Fax: 906-874-2124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MRS. NICKI LEE PRICE
Title or Position: PT
Credential:
Phone: 906-284-3497