Provider Demographics
NPI:1992907794
Name:ENRIQUEZ, EDUARDO ALBERTO (P T PC)
Entity type:Individual
Prefix:
First Name:EDUARDO
Middle Name:ALBERTO
Last Name:ENRIQUEZ
Suffix:
Gender:M
Credentials:P T PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5778 NEW MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-7164
Mailing Address - Country:US
Mailing Address - Phone:734-439-8410
Mailing Address - Fax:734-439-8430
Practice Address - Street 1:905 DEXTER ST
Practice Address - Street 2:
Practice Address - City:MILAN
Practice Address - State:MI
Practice Address - Zip Code:48160-1160
Practice Address - Country:US
Practice Address - Phone:734-439-8410
Practice Address - Fax:734-439-8430
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-04
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004167225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10425482410Medicaid
MI383322512OtherCOMMERCIAL
MI650D657010OtherBLUE CROSS BLUE SHIELD
MI6346200001Medicare NSC
MIB48200Medicare UPIN
MIP23500001Medicare PIN