Healthcare Provider Details

I. General information

NPI: 1275619538
Provider Name (Legal Business Name): JON DAVID ELY PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5590 MAIN ST. SUITE 4
LEXINGTON MI
48450
US

IV. Provider business mailing address

PO BOX 416 5590 MAIN STREET , SUITE 4
LEXINGTON MI
48450-0416
US

V. Phone/Fax

Practice location:
  • Phone: 810-359-8700
  • Fax: 810-359-8702
Mailing address:
  • Phone: 810-359-8700
  • Fax: 810-359-8702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501008405
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: