Healthcare Provider Details

I. General information

NPI: 1598783854
Provider Name (Legal Business Name): PROMODH JOSEPH PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7762 NORTH FEDERAL RD
HOWARD CITY MI
49329
US

IV. Provider business mailing address

7762 NORTH FEDERAL RD P.O.BOX 256
HOWARD CITY MI
49329
US

V. Phone/Fax

Practice location:
  • Phone: 231-937-8485
  • Fax: 231-937-9836
Mailing address:
  • Phone: 231-937-8485
  • Fax: 231-937-9836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501007640
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: