Healthcare Provider Details

I. General information

NPI: 1316321052
Provider Name (Legal Business Name): ITHACA PHYSICAL THERAPY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 02/01/2024
Certification Date: 02/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 DILTS RD
ITHACA MI
48847-9475
US

IV. Provider business mailing address

203 DILTS RD
ITHACA MI
48847-9475
US

V. Phone/Fax

Practice location:
  • Phone: 989-875-2266
  • Fax: 989-875-2225
Mailing address:
  • Phone: 989-875-2266
  • Fax: 989-875-2225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501008948
License Number StateMI

VIII. Authorized Official

Name: JOSEPH BAXTER
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 989-875-2266