=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649772922
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSE BENJAMIN F RUSTIA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2018
-----------------------------------------------------
Last Update Date | 03/02/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 W RUSSELL ST
-----------------------------------------------------
City | SALINE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48176-1184
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-429-9401
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1531 NATALIE LN APT 302
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48105-2935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 5501017663
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------