Provider Demographics
NPI:1528123304
Name:HERITAGE PHYSICAL THERAPY, PLLC
Entity type:Organization
Organization Name:HERITAGE PHYSICAL THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTONI
Authorized Official - Middle Name:
Authorized Official - Last Name:LODZINSKI
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, PT, ATC
Authorized Official - Phone:248-366-0403
Mailing Address - Street 1:2891 E MAPLE RD
Mailing Address - Street 2:STE 103
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-6106
Mailing Address - Country:US
Mailing Address - Phone:248-720-0701
Mailing Address - Fax:
Practice Address - Street 1:2891 E MAPLE RD
Practice Address - Street 2:STE 103
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-6106
Practice Address - Country:US
Practice Address - Phone:248-720-0701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-22
Last Update Date:2008-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P25860Medicare ID - Type Unspecified