Healthcare Provider Details

I. General information

NPI: 1295995629
Provider Name (Legal Business Name): PHYSICAL THERAPY SERVICES OF GRAND RAPIDS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4070 LAKE DR SE SUITE: 204
GRAND RAPIDS MI
49546-8294
US

IV. Provider business mailing address

4070 LAKE DR SE SUITE: 204
GRAND RAPIDS MI
49546-8294
US

V. Phone/Fax

Practice location:
  • Phone: 616-481-3690
  • Fax:
Mailing address:
  • Phone: 616-481-3690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. KATHY LOU CARRIER
Title or Position: MEMBER
Credential: PT
Phone: 616-481-3690