Healthcare Provider Details

I. General information

NPI: 1770419491
Provider Name (Legal Business Name): BRET DANIEL BOISCLAIR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2505 N LONG LAKE RD
FENTON MI
48430-8840
US

IV. Provider business mailing address

2505 N LONG LAKE RD
FENTON MI
48430-8840
US

V. Phone/Fax

Practice location:
  • Phone: 810-471-0180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004370
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: