MEDICARE: MR. COREY MATHEW SOBECK PT

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	225100000X	Physical Therapist	5501011221	MI

General Provider Information

NPI Number	:	1700989761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. COREY MATHEW SOBECK PT

Provider Business Mailing Address
First Line	:	11794 8TH AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534
Country	:	US
Telephone Number	:	616-677-5432
Fax Number	:

Provider Business Practice Location Address
First Line	:	1175 WILSON AVE NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49534-3493
Country	:	US
Telephone Number	:	616-284-3686
Fax Number	:	616-301-1984

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

Provider Enumeration Date	:	09/06/2006
Last Update Date	:	10/08/2008

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