Healthcare Provider Details

I. General information

NPI: 1275014680
Provider Name (Legal Business Name): BRIAN BASSIL KANONA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29187 RYAN RD
WARREN MI
48092-4243
US

IV. Provider business mailing address

3780 MILANO CT
ROCHESTER HILLS MI
48307-2245
US

V. Phone/Fax

Practice location:
  • Phone: 586-578-9239
  • Fax:
Mailing address:
  • Phone: 248-787-4717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501018759
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: