Healthcare Provider Details

I. General information

NPI: 1306034772
Provider Name (Legal Business Name): MELTON PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2007
Last Update Date: 10/10/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 S OTSEGO AVE
GAYLORD MI
49735-9171
US

IV. Provider business mailing address

1050 S OTSEGO AVE
GAYLORD MI
49735-9171
US

V. Phone/Fax

Practice location:
  • Phone: 989-731-6781
  • Fax: 989-705-8448
Mailing address:
  • Phone: 989-731-6781
  • Fax: 989-705-8448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501009879
License Number StateMI

VIII. Authorized Official

Name: MR. MARK R MELTON
Title or Position: PRESIDENT/OWNER
Credential: PHYSICAL THERAPIST
Phone: 231-258-6789