Healthcare Provider Details

I. General information

NPI: 1316581226
Provider Name (Legal Business Name): FYZICAL THERAPY AND BALANCE CENTER BY THE BAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2019
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2609 CHARLEVOIX RD
PETOSKEY MI
49770-8524
US

IV. Provider business mailing address

2609 CHARLEVOIX RD
PETOSKEY MI
49770-8524
US

V. Phone/Fax

Practice location:
  • Phone: 231-439-3750
  • Fax: 231-439-5918
Mailing address:
  • Phone: 231-439-3750
  • Fax: 231-439-5918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DIANA TAHTINEN
Title or Position: OFFICE MANAGER
Credential:
Phone: 231-439-3750