=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154865046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRUM PHYSICAL THERAPY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2016
-----------------------------------------------------
Last Update Date | 12/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1501 S CENTER RD BUILDING A
-----------------------------------------------------
City | BURTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48509-1731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-715-7746
-----------------------------------------------------
Fax | 810-715-7716
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1501 S CENTER RD BUILDING A
-----------------------------------------------------
City | BURTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48509-1731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-715-7746
-----------------------------------------------------
Fax | 810-715-7716
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLER
-----------------------------------------------------
Name | MS. CHELSEA LEEANN ROLFE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 810-715-7746
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 5501006027
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------