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General NPI Number Information
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NPI Number | 1952420358
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Entity Type | Organization
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Legal Business Name | UPPER PENINSULS SPORTS MEDICINE & THERAPY CENTER
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Dates
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Enumeration Date | 03/28/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 1414 W FAIR AVE SUITE 101
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City | MARQUETTE
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State | MI
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Zip | 49855-2675
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Country | US
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Telephone | 906-228-2595
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Fax | 906-228-3313
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Provider Business Mailing Address
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Address Line | 1414 W FAIR AVE SUITE 101
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City | MARQUETTE
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State | MI
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Zip | 49855-2675
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Country | US
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Telephone | 906-228-2595
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Fax | 906-228-3313
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. DEBRA LEE NEVENHOVEN
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Credential |
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Telephone | 906-228-2595
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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 | 5501001972
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License Number State | MI
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