1164481958 NPI number — MITCHELL JASON SMELIS ATC

Table of content: MITCHELL JASON SMELIS ATC (NPI 1164481958)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164481958 NPI number — MITCHELL JASON SMELIS ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMELIS
Provider First Name:
MITCHELL
Provider Middle Name:
JASON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ATC
Provider Gender Code:
M

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:
1164481958
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3240 W SILVER LAKE RD
Provider Second Line Business Mailing Address:
PHYSIOTHERAPY ASSOCIATES
Provider Business Mailing Address City Name:
FENTON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48430-1374
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-714-4616
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3200 W SHIAWASSEE AVE
Provider Second Line Business Practice Location Address:
FENTON HIGH SCHOOL ATHLETICS
Provider Business Practice Location Address City Name:
FENTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48430-1762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-591-2629
Provider Business Practice Location Address Fax Number:
810-591-2624
Provider Enumeration Date:
03/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  2601000415 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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