Healthcare Provider Details

I. General information

NPI: 1306980735
Provider Name (Legal Business Name): GAUTAM ARORA PHYSICAL THERAPIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2920 FULLER AVE NE SUITE 100
GRAND RAPIDS MI
49505-3458
US

IV. Provider business mailing address

4265 ARLET CT SE
GRAND RAPIDS MI
49546-8276
US

V. Phone/Fax

Practice location:
  • Phone: 616-361-8355
  • Fax: 616-361-8354
Mailing address:
  • Phone: 616-285-9261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501006066
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: