Provider Demographics
NPI:1013228030
Name:MEYER, MIKE (PTA)
Entity Type:Individual
Prefix:
First Name:MIKE
Middle Name:
Last Name:MEYER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 W LINWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LINWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:48634-9783
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 ROCKWELL DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-9316
Practice Address - Country:US
Practice Address - Phone:989-633-5372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000782314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility