=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063736296
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOCUS PT SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2010
-----------------------------------------------------
Last Update Date | 03/17/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9245 AUSTIN DR
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49002-6403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-361-9396
-----------------------------------------------------
Fax | 269-321-0156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9245 AUSTIN DR
-----------------------------------------------------
City | PORTAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49002-6403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-361-9396
-----------------------------------------------------
Fax | 269-321-0156
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ALFONSO EMANUEL RODRIGUEZ
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 574-361-9396
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501004277
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------