Healthcare Provider Details

I. General information

NPI: 1609341619
Provider Name (Legal Business Name): EDSEL D OBRA PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2018
Last Update Date: 10/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37764 IRENE DR
STERLING HEIGHTS MI
48312-1934
US

IV. Provider business mailing address

37764 IRENE DR
STERLING HEIGHTS MI
48312-1934
US

V. Phone/Fax

Practice location:
  • Phone: 586-722-4735
  • Fax: 586-264-8525
Mailing address:
  • Phone: 586-722-4735
  • Fax: 586-264-8525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501011778
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: