MEDICARE: ALANS PHYSICAL THERAPY OF GRAND RAPIDS

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	7152	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811313612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALANS PHYSICAL THERAPY OF GRAND RAPIDS

Provider Business Mailing Address
First Line	:	111 GOLF COURSE RD
Second Line	:	SUITE 2
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-3526
Country	:	US
Telephone Number	:	218-999-5554
Fax Number	:	218-999-7620

Provider Business Practice Location Address
First Line	:	111 GOLF COURSE RD
Second Line	:	SUITE 2
City	:	GRAND RAPIDS
State	:	MN
Zip	:	55744-3526
Country	:	US
Telephone Number	:	218-999-5554
Fax Number	:	218-999-7620

Authorized Official
Title or Position	:	OWNER
Name	:	ALAN JAY DETTMER
Credential	:	PT
Telephone Number	:	218-999-5554

Provider Enumeration Date	:	03/17/2014
Last Update Date	:	06/26/2014

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