Provider Demographics
NPI:1992876221
Name:RED CEDAR PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:RED CEDAR PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SELENA
Authorized Official - Middle Name:A
Authorized Official - Last Name:HORNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:517-655-8569
Mailing Address - Street 1:1218 E GRAND RIVER RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48895-9335
Mailing Address - Country:US
Mailing Address - Phone:517-655-8569
Mailing Address - Fax:517-655-8604
Practice Address - Street 1:1218 E GRAND RIVER RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTON
Practice Address - State:MI
Practice Address - Zip Code:48895-9335
Practice Address - Country:US
Practice Address - Phone:517-655-8569
Practice Address - Fax:517-655-8604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006535225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P18190Medicare PIN