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General NPI Number Information
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NPI Number | 1255667556
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Entity Type | Organization
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Legal Business Name | ABYSSINIA LOVE KNOT PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 10/22/2009
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Last Update Date | 09/09/2019
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Provider Practice Location Address
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Address Line | 15340 SOUTHFIELD FREEWAY SUITE 1-A
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City | DETROIT
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State | MI
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Zip | 48223
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Country | US
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Telephone | 313-646-6929
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Fax | 313-646-6929
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Provider Business Mailing Address
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Address Line | 21700 GREENFIELD RD SUITE 215
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City | OAK PARK
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State | MI
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Zip | 48237-2581
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Country | US
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Telephone | 248-968-6899
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Fax | 248-968-4443
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Authorized Official
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Title or Position | ADMINISTRATOR APPROPRIATIONS CASE M
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Name | MS. SHIRLEY A. DOUGLAS
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Credential | M.A.P.M, D.D.
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Telephone | 313-646-6929
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number |
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License Number State |
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