MEDICARE: MR. RYAN FAKULT DPT

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	5501016650	MI

General Provider Information

NPI Number	:	1821131228
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN FAKULT DPT

Provider Business Mailing Address
First Line	:	33900 HARPER AVE STE 104
Second Line	:
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48035-4258
Country	:	US
Telephone Number	:	586-350-2644
Fax Number	:	586-541-3735

Provider Business Practice Location Address
First Line	:	18161 W 13 MILE RD STE A1
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-1113
Country	:	US
Telephone Number	:	248-633-2640
Fax Number	:	248-633-2643

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

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	04/06/2026

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