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General NPI Number Information
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NPI Number | 1124401625
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Entity Type | Organization
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Legal Business Name | GREAT LAKES PHYSICAL THERAPY AND REHABILITATION LLC
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Dates
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Enumeration Date | 07/01/2015
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Last Update Date | 07/01/2015
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Provider Practice Location Address
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Address Line | 12434 E 12 MILE RD STE 101
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City | WARREN
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State | MI
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Zip | 48093-3536
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Country | US
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Telephone | 586-578-9121
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Fax | 586-578-9124
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Provider Business Mailing Address
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Address Line | 12434 E 12 MILE RD STE 101
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City | WARREN
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State | MI
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Zip | 48093-3536
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Country | US
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Telephone | 586-578-9121
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Fax | 586-578-9124
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. DAVID JAMES STAPELS
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Credential |
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Telephone | 586-321-4563
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | E6533E
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License Number State | MI
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