Healthcare Provider Details

I. General information

NPI: 1528123304
Provider Name (Legal Business Name): HERITAGE PHYSICAL THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2891 E MAPLE RD STE 103
TROY MI
48083-6106
US

IV. Provider business mailing address

2891 E MAPLE RD STE 103
TROY MI
48083-6106
US

V. Phone/Fax

Practice location:
  • Phone: 248-720-0701
  • Fax:
Mailing address:
  • Phone: 248-720-0701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANTONI LODZINSKI
Title or Position: ADMINISTRATOR
Credential: PHD, P.T., A.T.C.
Phone: 248-366-0403