Healthcare Provider Details

I. General information

NPI: 1447739271
Provider Name (Legal Business Name): JOHN GREGORY POOLE PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51635 10 MILE RD
SOUTH LYON MI
48178-9720
US

IV. Provider business mailing address

33900 HARPER AVE STE 104
CLINTON TWP MI
48035-4258
US

V. Phone/Fax

Practice location:
  • Phone: 248-278-1072
  • Fax: 248-278-1073
Mailing address:
  • Phone: 586-350-2644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11974
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501020066
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: