1902814312 NPI number — NLJ PHYSICAL THERAPY CENTER P.C.

Table of content: (NPI 1902814312)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902814312 NPI number — NLJ PHYSICAL THERAPY CENTER P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NLJ PHYSICAL THERAPY CENTER P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902814312
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
901 PYLE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49802-4452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-774-3779
Provider Business Mailing Address Fax Number:
906-774-6712

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
901 PYLE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49802-4452
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-774-3779
Provider Business Practice Location Address Fax Number:
906-774-6712
Provider Enumeration Date:
08/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
NEAL
Authorized Official Middle Name:
LORN
Authorized Official Title or Position:
OWNER PRESIDENT OF CLINIC
Authorized Official Telephone Number:
906-774-3779

Provider Taxonomy Codes

  • Taxonomy code: 208100000X , with the licence number:  5501003258 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208100000X , with the licence number: 4326024 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 380747012 . This is a "TRICARE NORTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1009687 . This is a "PREFERRED ONE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 650012048 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 650B257010 . This is a "BCBS OF MICH" identifier . This identifiers is of the category "OTHER".




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