MEDICARE: PRO HEALTH PHYSICAL THERAPY PC

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

General Provider Information

NPI Number	:	1811362304
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRO HEALTH PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	5700 EXECUTIVE DR
Second Line	:	SUITE 3
City	:	LANSING
State	:	MI
Zip	:	48911-5301
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5700 EXECUTIVE DR
Second Line	:	SUITE 3
City	:	LANSING
State	:	MI
Zip	:	48911-5301
Country	:	US
Telephone Number	:	517-402-4696
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. KUMPATI SOBHA
Credential	:	MHS PT
Telephone Number	:	517-918-9213

Provider Enumeration Date	:	12/09/2015
Last Update Date	:	12/09/2015

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