Healthcare Provider Details

I. General information

NPI: 1811496359
Provider Name (Legal Business Name): SOUL PHYSICAL THERAPY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/11/2018
Last Update Date: 02/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6558 GREENFIELD RD
DEARBORN MI
48126-1701
US

IV. Provider business mailing address

PO BOX 86
DEARBORN MI
48121-0086
US

V. Phone/Fax

Practice location:
  • Phone: 313-581-1155
  • Fax: 313-581-1144
Mailing address:
  • Phone: 313-581-1155
  • Fax: 313-581-1144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: AMENEH REZVAN
Title or Position: PRESIDENT/ MANAGER
Credential:
Phone: 248-884-0048