Healthcare Provider Details

I. General information

NPI: 1134502644
Provider Name (Legal Business Name): STEVEN VACULIK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2015
Last Update Date: 07/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 S MAIN ST STE 220
PLYMOUTH MI
48170-2089
US

IV. Provider business mailing address

705 S MAIN ST STE 220
PLYMOUTH MI
48170-2089
US

V. Phone/Fax

Practice location:
  • Phone: 877-248-9321
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number015477
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: