=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457890592
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESSENCE PHYSICAL THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2017
-----------------------------------------------------
Last Update Date | 02/22/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1324 LAKE DR SE SUITE 3
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49506-1673
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-481-6661
-----------------------------------------------------
Fax | 844-965-9569
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 537 GLADSTONE DR SE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49506-2816
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-481-6661
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. RACHEL ELIZABETH DAVIES
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 616-481-6661
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501011332
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------