Healthcare Provider Details

I. General information

NPI: 1710948757
Provider Name (Legal Business Name): EDO ZYLSTRA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4676 32ND AVE STE C
HUDSONVILLE MI
49426-8015
US

IV. Provider business mailing address

5135 HIDE AWAY LN
HUDSONVILLE MI
49426-7373
US

V. Phone/Fax

Practice location:
  • Phone: 616-263-6161
  • Fax:
Mailing address:
  • Phone: 303-263-7041
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7515
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501016106
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: