Provider Demographics
NPI:1114226222
Name:MENDELSON KORNBLUM PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MENDELSON KORNBLUM PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PT SUPRIVISOR
Authorized Official - Prefix:
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:
Authorized Official - Last Name:PRING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-582-0340
Mailing Address - Street 1:29703 HOOVER RD STE A
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-8901
Mailing Address - Country:US
Mailing Address - Phone:586-582-0340
Mailing Address - Fax:
Practice Address - Street 1:29703 HOOVER RD STE A
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-8901
Practice Address - Country:US
Practice Address - Phone:586-582-0340
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL18623592255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty