Healthcare Provider Details

I. General information

NPI: 1306129390
Provider Name (Legal Business Name): JUSTIN MATTHEW NIEMI PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 2ND ST
SPRING ARBOR MI
49283-9647
US

IV. Provider business mailing address

151 2ND ST
SPRING ARBOR MI
49283-9647
US

V. Phone/Fax

Practice location:
  • Phone: 517-750-4412
  • Fax: 517-750-4432
Mailing address:
  • Phone: 517-750-4412
  • Fax: 517-750-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502000830
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: