=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992529408
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIME PT SPECIALISTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2024
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39630 W 14 MILE RD
-----------------------------------------------------
City | COMMERCE TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48390-3909
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-561-9539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1906 TWIN SUN CIR
-----------------------------------------------------
City | WALLED LAKE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48390-4404
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-561-9539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PHYSICAL THERAPIST
-----------------------------------------------------
Name | JAIME DAVEY
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 248-561-9539
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------