Healthcare Provider Details

I. General information

NPI: 1417428384
Provider Name (Legal Business Name): PERCIVAL U MOHAMMAD PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2018
Last Update Date: 12/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34505 W 12 MILE RD
FARMINGTON HILLS MI
48331-3258
US

IV. Provider business mailing address

9904 LANCASTER DR
BELLEVILLE MI
48111-1691
US

V. Phone/Fax

Practice location:
  • Phone: 734-343-7500
  • Fax: 734-343-7501
Mailing address:
  • Phone: 734-558-2838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501004612
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: