Provider Demographics
NPI:1063980373
Name:FUEL PHYSICAL THERAPY & SPORTS PERFORMANCE, LLC
Entity type:Organization
Organization Name:FUEL PHYSICAL THERAPY & SPORTS PERFORMANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BROADWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:810-347-5219
Mailing Address - Street 1:1139 HOUSEMAN AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1229
Mailing Address - Country:US
Mailing Address - Phone:810-347-5219
Mailing Address - Fax:
Practice Address - Street 1:1139 HOUSEMAN AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1229
Practice Address - Country:US
Practice Address - Phone:810-347-5219
Practice Address - Fax:616-259-4226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-05
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty