Healthcare Provider Details

I. General information

NPI: 1134735871
Provider Name (Legal Business Name): WESTON CURTIS WYLIE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2020
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3070 13 MILE RD NE
ROCKFORD MI
49341-8070
US

IV. Provider business mailing address

3070 13 MILE RD NE
ROCKFORD MI
49341-8070
US

V. Phone/Fax

Practice location:
  • Phone: 616-308-3445
  • Fax:
Mailing address:
  • Phone: 616-308-3445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004185
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: