Healthcare Provider Details

I. General information

NPI: 1083624969
Provider Name (Legal Business Name): HEALTH SOURCE PHYSICAL THERAPY CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1447 E GRAND RIVER AVE
PORTLAND MI
48875-1631
US

IV. Provider business mailing address

1447 E GRAND RIVER AVE
PORTLAND MI
48875-1631
US

V. Phone/Fax

Practice location:
  • Phone: 517-647-1000
  • Fax: 517-647-1100
Mailing address:
  • Phone: 517-647-1000
  • Fax: 517-647-1100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number5501005495
License Number StateMI

VIII. Authorized Official

Name: MR. JAYA P BODDU
Title or Position: PRESIDENT
Credential:
Phone: 517-647-1000