Provider Demographics
NPI:1003931114
Name:DIVERSA CARE THERAPEUTICS, INC
Entity Type:Organization
Organization Name:DIVERSA CARE THERAPEUTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:989-992-1671
Mailing Address - Street 1:12 KINGSLEY CT
Mailing Address - Street 2:
Mailing Address - City:FRANKENMUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48734-1270
Mailing Address - Country:US
Mailing Address - Phone:989-992-1671
Mailing Address - Fax:
Practice Address - Street 1:12 KINGSLEY CT
Practice Address - Street 2:
Practice Address - City:FRANKENMUTH
Practice Address - State:MI
Practice Address - Zip Code:48734-1270
Practice Address - Country:US
Practice Address - Phone:989-992-1671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005682225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty