1811209968 NPI number — SPINE AND EXTREMITY INSTITUTE OF SOUTH LYON, L.L.C.

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 1811209968 NPI number — SPINE AND EXTREMITY INSTITUTE OF SOUTH LYON, L.L.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINE AND EXTREMITY INSTITUTE OF SOUTH LYON, L.L.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:
6
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:
1811209968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22180 PONTIAC TRAIL
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
SOUTH LYON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48178-9097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-446-0155
Provider Business Mailing Address Fax Number:
248-446-0177

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
22180 PONTIAC TRAIL
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
SOUTH LYON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48178-9097
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-446-0155
Provider Business Practice Location Address Fax Number:
248-446-0177
Provider Enumeration Date:
07/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
BROSTROM
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
ALEXANDER
Authorized Official Title or Position:
OWNER/DIRECTOR OF PHYSICAL THERAPY
Authorized Official Telephone Number:
248-446-0155

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5501010651 , 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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