Healthcare Provider Details

I. General information

NPI: 1043858160
Provider Name (Legal Business Name): DILLON OMMODT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2019
Last Update Date: 05/24/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2973 SPRINGPORT RD
JACKSON MI
49201-9060
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 517-435-3461
  • Fax: 517-768-9951
Mailing address:
  • Phone: 630-575-1980
  • Fax: 630-928-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501019436
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: