Provider Demographics
NPI:1073863874
Name:MASTERCARE PHYSICAL THERAPY AND WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:MASTERCARE PHYSICAL THERAPY AND WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-494-3873
Mailing Address - Street 1:6909 HIGHLAND RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1648
Mailing Address - Country:US
Mailing Address - Phone:248-674-5277
Mailing Address - Fax:248-674-5871
Practice Address - Street 1:6909 HIGHLAND RD
Practice Address - Street 2:SUITE B
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48327-1648
Practice Address - Country:US
Practice Address - Phone:248-674-5277
Practice Address - Fax:248-674-5871
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501300653225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty