Healthcare Provider Details

I. General information

NPI: 1669727871
Provider Name (Legal Business Name): BRODERICK EARL PEARISO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2012
Last Update Date: 07/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3370 E JOLLY RD
LANSING MI
48910-8552
US

IV. Provider business mailing address

3370 E JOLLY RD
LANSING MI
48910-8552
US

V. Phone/Fax

Practice location:
  • Phone: 517-332-7246
  • Fax: 517-332-1474
Mailing address:
  • Phone: 517-332-7246
  • Fax: 517-332-1474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502001428
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: