=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417929043
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN CHARLES NALAZEK PT, OMPT, CWT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2006
-----------------------------------------------------
Last Update Date | 09/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18791 15 MILE RD
-----------------------------------------------------
City | CLINTON TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48035-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-790-2326
-----------------------------------------------------
Fax | 586-790-2476
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18791 15 MILE RD
-----------------------------------------------------
City | CLINTON TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48035-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-790-2326
-----------------------------------------------------
Fax | 586-790-2476
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501004297
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------