Healthcare Provider Details

I. General information

NPI: 1740700566
Provider Name (Legal Business Name): NORTHWOODS PT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 07/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5782 US HIGHWAY 31 N
WILLIAMSBURG MI
49690-9312
US

IV. Provider business mailing address

5782 US HIGHWAY 31 N
WILLIAMSBURG MI
49690-9312
US

V. Phone/Fax

Practice location:
  • Phone: 231-938-2425
  • Fax:
Mailing address:
  • Phone: 231-938-2425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501016687
License Number StateMI

VIII. Authorized Official

Name: MISTEN BOYSEN
Title or Position: OWNER
Credential: DPT
Phone: 720-255-6992