Provider Demographics
NPI:1003253170
Name:NORTHSPORT PHYSICAL THERAPY & REHABILITATION PC
Entity Type:Organization
Organization Name:NORTHSPORT PHYSICAL THERAPY & REHABILITATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:C
Authorized Official - Last Name:PETRIE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:989-848-2525
Mailing Address - Street 1:1622 DICKERSON RD
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9206
Mailing Address - Country:US
Mailing Address - Phone:989-848-2525
Mailing Address - Fax:989-848-2999
Practice Address - Street 1:1968 E MILLER RD
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:MI
Practice Address - Zip Code:48621-8717
Practice Address - Country:US
Practice Address - Phone:989-848-2525
Practice Address - Fax:989-848-2999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-30
Last Update Date:2013-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty