Healthcare Provider Details

I. General information

NPI: 1801095146
Provider Name (Legal Business Name): JASON DONALD KROULIK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 12/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23852 MICHIGAN AVE
DEARBORN MI
48124-1829
US

IV. Provider business mailing address

33200 W 14 MILE RD
WEST BLOOMFIELD MI
48322-3563
US

V. Phone/Fax

Practice location:
  • Phone: 313-565-4222
  • Fax: 313-565-8703
Mailing address:
  • Phone: 248-538-7607
  • Fax: 248-538-7623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501013385
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: