1225448509 NPI number — VICTORY PHYSICAL THERAPY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225448509 NPI number — VICTORY PHYSICAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VICTORY PHYSICAL THERAPY
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:
1225448509
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23300 GREENFIELD RD
Provider Second Line Business Mailing Address:
SUITE 105
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48237-5237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-268-3180
Provider Business Mailing Address Fax Number:
248-268-3182

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
23300 GREENFIELD RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
OAK PARK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48237-5237
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-268-3180
Provider Business Practice Location Address Fax Number:
248-268-3182
Provider Enumeration Date:
05/07/2014

Additional Information

Authorized Official

Authorized Official Last Name:
SAGALA
Authorized Official First Name:
GEOFFREY
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
313-595-5668

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  E4330N , 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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