Provider Demographics
NPI:1043610074
Name:VICTOR, JUSTIN NICHOLAS (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:NICHOLAS
Last Name:VICTOR
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15285 OCEANA AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-1955
Mailing Address - Country:US
Mailing Address - Phone:313-587-0812
Mailing Address - Fax:
Practice Address - Street 1:2900 CHARLEVOIX DR SE
Practice Address - Street 2:#200
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7085
Practice Address - Country:US
Practice Address - Phone:616-975-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60747438225100000X
MI5501016888225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist