=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689140071
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXANDER HOLDREN DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2018
-----------------------------------------------------
Last Update Date | 10/11/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14229 TORREY RD
-----------------------------------------------------
City | FENTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48430-3308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-433-4600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27310 THORNRIDGE DR
-----------------------------------------------------
City | GRAND BLANC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48439-9285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-526-2530
-----------------------------------------------------
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 | PTL.0016671
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 5501018898
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------