Healthcare Provider Details

I. General information

NPI: 1174970404
Provider Name (Legal Business Name): ATHLETICO LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43443 GRAND RIVER AVE SUITE 200
NOVI MI
48375-1106
US

IV. Provider business mailing address

625 ENTERPRISE DR
OAK BROOK IL
60523-8813
US

V. Phone/Fax

Practice location:
  • Phone: 248-305-9200
  • Fax: 248-305-9330
Mailing address:
  • Phone: 630-575-1932
  • Fax: 630-928-5032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUANA GRANADOS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 630-575-1980