Healthcare Provider Details

I. General information

NPI: 1003338898
Provider Name (Legal Business Name): JOSHUA PAUL AHLSTROM CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 07/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 E MICHIGAN AVE
JACKSON MI
49202-3517
US

IV. Provider business mailing address

1407 E MICHIGAN AVE
JACKSON MI
49202-3517
US

V. Phone/Fax

Practice location:
  • Phone: 517-784-1142
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberCPO2466
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: