Provider Demographics
NPI:1215974613
Name:EDUARDO A. ENRIQUEZ, P T PC
Entity type:Organization
Organization Name:EDUARDO A. ENRIQUEZ, P T PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:ALBERTO
Authorized Official - Last Name:ENRIQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:734-439-8410
Mailing Address - Street 1:905 DEXTER ST
Mailing Address - Street 2:
Mailing Address - City:MILAN
Mailing Address - State:MI
Mailing Address - Zip Code:48160-1160
Mailing Address - Country:US
Mailing Address - Phone:734-439-8410
Mailing Address - Fax:734-439-8430
Practice Address - Street 1:905 DEXTER ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MI
Practice Address - Zip Code:48160-1160
Practice Address - Country:US
Practice Address - Phone:734-439-8410
Practice Address - Fax:734-439-8430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225100000X225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI16866OtherMCARE PIN NUMBER
MI650D657010OtherBLUE CROSS PROVIDER CODE
MI10425482410Medicaid
MI16866OtherMCARE PIN NUMBER
MIB48200Medicare UPIN
MI0P23500Medicare PIN