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General NPI Number Information
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NPI Number | 1659675346
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Entity Type | Individual
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Provider Name | NATHAN MICHAEL BENJAMIN PTA
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Gender | Male
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Dates
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Enumeration Date | 01/10/2011
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Last Update Date | 01/10/2011
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Provider Practice Location Address
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Address Line | 1235 S CENTER RD STE 12
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City | BURTON
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State | MI
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Zip | 48509-1700
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Country | US
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Telephone | 810-743-8820
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Fax | 810-743-5908
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Provider Business Mailing Address
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Address Line | 7601 LIONS GATE PKWY
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City | DAVISON
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State | MI
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Zip | 48423-3195
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 5502003080
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License Number State | MI
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