Provider Demographics
NPI:1285724039
Name:KOOP FAMILY PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:KOOP FAMILY PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER OF LLC
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:LEE SHINE
Authorized Official - Last Name:KOOP
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:419-471-0400
Mailing Address - Street 1:4859 W SYLVANIA AVE STE A
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-3372
Mailing Address - Country:US
Mailing Address - Phone:419-471-0400
Mailing Address - Fax:419-471-0403
Practice Address - Street 1:4859 W SYLVANIA AVE STE A
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-3372
Practice Address - Country:US
Practice Address - Phone:419-471-0400
Practice Address - Fax:419-471-0403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH009627225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2714094Medicaid
OH2714094Medicaid