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General NPI Number Information
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NPI Number | 1598903759
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Entity Type | Organization
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Legal Business Name | PT 360 PHYSICAL THERAPY, PLC
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Dates
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Enumeration Date | 01/27/2009
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Last Update Date | 02/27/2009
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Provider Practice Location Address
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Address Line | 1502 WEALTHY ST
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City | GRAND RAPIDS
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State | MI
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Zip | 49506
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Country | US
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Telephone | 616-776-7771
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Fax |
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Provider Business Mailing Address
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Address Line | P O BOX 6088
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City | GRAND RAPIDS
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State | MI
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Zip | 49516
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Country | US
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Telephone | 616-776-7771
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. DAVID A ASSELIN
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Credential | PT
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Telephone | 616-776-7771
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 5501013640
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License Number State | MI
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