Healthcare Provider Details

I. General information

NPI: 1720472301
Provider Name (Legal Business Name): WAYNE PARK LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27850 GRATIOT AVE
ROSEVILLE MI
48066-4803
US

IV. Provider business mailing address

57232 NEWPORT LN
WASHINGTON MI
48094-3033
US

V. Phone/Fax

Practice location:
  • Phone: 586-772-5876
  • Fax:
Mailing address:
  • Phone: 586-275-8008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberL581371
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: