Healthcare Provider Details

I. General information

NPI: 1962402891
Provider Name (Legal Business Name): DWIGHT ORTHO - WEST BLOOMFIELD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 04/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7115 ORCHARD LAKE RD SUITE 100
WEST BLOOMFIELD MI
48322-3678
US

IV. Provider business mailing address

42615 GARFIELD RD
CLINTON TOWNSHIP MI
48038-1653
US

V. Phone/Fax

Practice location:
  • Phone: 248-855-9009
  • Fax: 248-855-8460
Mailing address:
  • Phone: 586-412-2845
  • Fax: 586-416-1497

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501002195
License Number StateMI

VIII. Authorized Official

Name: MRS. GWYN SWARTZ
Title or Position: CORPORATE ADMINISTRATOR
Credential:
Phone: 586-412-2846