=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710475397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH WALL
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2018
-----------------------------------------------------
Last Update Date | 04/29/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8750 MONROE RD
-----------------------------------------------------
City | DURAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48429-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-288-3166
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8353 APPLE BLOSSOM LN
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48433-1192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-252-1798
-----------------------------------------------------
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 | 5501017586
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------