Provider Demographics
NPI:1346410826
Name:GRAND TRAVERSE PHYSICAL THERAPY, P.C.
Entity type:Organization
Organization Name:GRAND TRAVERSE PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:231-941-6500
Mailing Address - Street 1:735 S GARFIELD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3489
Mailing Address - Country:US
Mailing Address - Phone:231-941-6500
Mailing Address - Fax:231-941-6600
Practice Address - Street 1:735 S GARFIELD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3489
Practice Address - Country:US
Practice Address - Phone:231-941-6500
Practice Address - Fax:231-941-6600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N52680Medicare PIN