Provider Demographics
NPI:1386922508
Name:MICHIGAN SPINE AND JOINT PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:MICHIGAN SPINE AND JOINT PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:810-245-7799
Mailing Address - Street 1:PO BOX 757
Mailing Address - Street 2:
Mailing Address - City:GRAND BLANC
Mailing Address - State:MI
Mailing Address - Zip Code:48480-0757
Mailing Address - Country:US
Mailing Address - Phone:810-245-7799
Mailing Address - Fax:810-245-7789
Practice Address - Street 1:2401 W GENESEE ST
Practice Address - Street 2:SUITE A
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-1779
Practice Address - Country:US
Practice Address - Phone:810-245-7799
Practice Address - Fax:810-245-7789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty