=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922469071
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMROSE PHYSICAL & AQUATIC THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2016
-----------------------------------------------------
Last Update Date | 03/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22463 NORFOLK CT
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48374-3975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-513-6131
-----------------------------------------------------
Fax | 248-719-7711
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22463 NORFOLK CT
-----------------------------------------------------
City | NOVI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48374-3975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-513-6131
-----------------------------------------------------
Fax | 248-719-7711
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. DONNA RENEE BUTLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-885-9195
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------