=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841079092
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THRIVE PT GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2023
-----------------------------------------------------
Last Update Date | 09/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6069 RIDGEVIEW DR
-----------------------------------------------------
City | NORTON SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49441-6143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-670-7408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6069 RIDGEVIEW DR
-----------------------------------------------------
City | NORTON SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49441-6143
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-670-7408
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ANTHONY WOODARD
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 231-670-7408
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------