Provider Demographics
NPI:1013033604
Name:CLINT VERRAN SPORTS MEDICINE, INC
Entity Type:Organization
Organization Name:CLINT VERRAN SPORTS MEDICINE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLINT
Authorized Official - Middle Name:
Authorized Official - Last Name:VERRAN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-693-9411
Mailing Address - Street 1:1261 S LAPEER RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48360-1419
Mailing Address - Country:US
Mailing Address - Phone:248-693-9411
Mailing Address - Fax:248-693-9412
Practice Address - Street 1:1261 S LAPEER RD
Practice Address - Street 2:SUTIE 102
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48360-1419
Practice Address - Country:US
Practice Address - Phone:248-693-9411
Practice Address - Fax:248-693-9412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010788225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P15130Medicare PIN