Healthcare Provider Details

I. General information

NPI: 1033271036
Provider Name (Legal Business Name): LORI L KONOPACKE P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 01/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 E VAN RIPER RD STE 200
FOWLERVILLE MI
48836-7947
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 517-223-2100
  • Fax: 517-223-2101
Mailing address:
  • Phone: 630-296-2223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501003511
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: