Healthcare Provider Details

I. General information

NPI: 1114226222
Provider Name (Legal Business Name): MENDELSON KORNBLUM PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 03/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29703 HOOVER RD STE A
WARREN MI
48093-8901
US

IV. Provider business mailing address

29703 HOOVER RD STE A
WARREN MI
48093-8901
US

V. Phone/Fax

Practice location:
  • Phone: 586-582-0340
  • Fax:
Mailing address:
  • Phone: 586-582-0340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberL1862359
License Number StateMI

VIII. Authorized Official

Name: KATIE PRING
Title or Position: PT SUPRIVISOR
Credential:
Phone: 586-582-0340