Healthcare Provider Details

I. General information

NPI: 1649779331
Provider Name (Legal Business Name): JDR74 HOLDINGS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 02/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13060 S US HIGHWAY 27 STE C4
DEWITT MI
48820-9319
US

IV. Provider business mailing address

13060 S US HIGHWAY 27 STE C4
DEWITT MI
48820-9319
US

V. Phone/Fax

Practice location:
  • Phone: 517-449-7173
  • Fax:
Mailing address:
  • Phone: 517-449-7173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501014355
License Number StateMI

VIII. Authorized Official

Name: DR. RYAN MATTHEW RABORN
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 517-449-7173