Healthcare Provider Details
I. General information
NPI: 1962499855
Provider Name (Legal Business Name): PHYSICAL THERAPY ONE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:
II. Dates (important events)
Enumeration Date: 10/05/2005
Last Update Date: 06/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
1423 W CENTRE AVE
PORTAGE MI
49024-5351
US
IV. Provider business mailing address
1423 W CENTRE AVE
PORTAGE MI
49024-5351
US
V. Phone/Fax
- Phone: 269-323-4300
- Fax: 269-323-4449
- Phone: 269-323-4300
- Fax: 269-323-4449
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | N |
| Taxonomy Code | 225100000X |
| Taxonomy | Physical Therapist |
| License Number | 5501013485 |
| License Number State | MI |
| # 2 | |
| Primary Taxonomy | N |
| Taxonomy Code | 225200000X |
| Taxonomy | Physical Therapy Assistant |
| License Number | 5502000788 |
| License Number State | MI |
| # 3 | |
| Primary Taxonomy | N |
| Taxonomy Code | 225200000X |
| Taxonomy | Physical Therapy Assistant |
| License Number | 5502002365 |
| License Number State | MI |
| # 4 | |
| Primary Taxonomy | N |
| Taxonomy Code | 225100000X |
| Taxonomy | Physical Therapist |
| License Number | 5501012189 |
| License Number State | MI |
| # 5 | |
| Primary Taxonomy | N |
| Taxonomy Code | 225100000X |
| Taxonomy | Physical Therapist |
| License Number | 5501015684 |
| License Number State | MI |
| # 6 | |
| Primary Taxonomy | N |
| Taxonomy Code | 225100000X |
| Taxonomy | Physical Therapist |
| License Number | 5501013900 |
| License Number State | MI |
| # 7 | |
| Primary Taxonomy | N |
| Taxonomy Code | 225100000X |
| Taxonomy | Physical Therapist |
| License Number | 5501008430 |
| License Number State | MI |
| # 8 | |
| Primary Taxonomy | N |
| Taxonomy Code | 225100000X |
| Taxonomy | Physical Therapist |
| License Number | 5501011392 |
| License Number State | MI |
| # 9 | |
| Primary Taxonomy | N |
| Taxonomy Code | 225100000X |
| Taxonomy | Physical Therapist |
| License Number | 5501011041 |
| License Number State | MI |
| # 10 | |
| Primary Taxonomy | N |
| Taxonomy Code | 225100000X |
| Taxonomy | Physical Therapist |
| License Number | 5501004752 |
| License Number State | MI |
| # 11 | |
| Primary Taxonomy | N |
| Taxonomy Code | 225100000X |
| Taxonomy | Physical Therapist |
| License Number | 5501009829 |
| License Number State | MI |
| # 12 | |
| Primary Taxonomy | N |
| Taxonomy Code | 225100000X |
| Taxonomy | Physical Therapist |
| License Number | 5501010759 |
| License Number State | MI |
| # 13 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 225100000X |
| Taxonomy | Physical Therapist |
| License Number | 5501008230 |
| License Number State | MI |
VIII. Authorized Official
Name: MR.
JOSEPH
BRUCE
WALTERS
Title or Position: OWNER, PHYSICAL THERAPIST
Credential: M.S, P.T
Phone: 269-323-4300
