=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255935441
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEP FORWARD WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2020
-----------------------------------------------------
Last Update Date | 07/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 401 HALL ST SW STE 112E
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-6500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-646-4221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 401 HALL ST SW STE 112E
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49503-6500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-646-4221
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRANDON YUENGER
-----------------------------------------------------
Credential | PT, DPT, CIDN
-----------------------------------------------------
Telephone | 734-646-4221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------