Healthcare Provider Details

I. General information

NPI: 1255352571
Provider Name (Legal Business Name): KRYSTAL MATESIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19701 VERNIER RD
HARPER WOODS MI
48225-1467
US

IV. Provider business mailing address

32224 PIERCE ST
GARDEN CITY MI
48135-3238
US

V. Phone/Fax

Practice location:
  • Phone: 313-884-8920
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501009514
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: