MEDICARE: MR. WIMAL JAYAKODY PHYSICAL THERAPIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2000X	Physical Therapy Clinic/Center	5501005942	MI

General Provider Information

NPI Number	:	1053882399
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WIMAL JAYAKODY PHYSICAL THERAPIST

Provider Business Mailing Address
First Line	:	1259 AZIZ DR
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-5092
Country	:	US
Telephone Number	:	734-846-7183
Fax Number	:

Provider Business Practice Location Address
First Line	:	1259 AZIZ DR
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-5092
Country	:	US
Telephone Number	:	734-846-7183
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2018
Last Update Date	:	12/16/2018

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