Provider Demographics
NPI:1083203400
Name:GRAND RAPIDS PHYSICAL THERAPY & PERFORMANCE
Entity Type:Organization
Organization Name:GRAND RAPIDS PHYSICAL THERAPY & PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PT
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:HANISKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:989-780-2748
Mailing Address - Street 1:1236 PLYMOUTH AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-5641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1236 PLYMOUTH AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-5641
Practice Address - Country:US
Practice Address - Phone:989-780-2748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Single Specialty