Provider Demographics
NPI:1164682399
Name:ORTHOPEDIC EDGE LLC
Entity Type:Organization
Organization Name:ORTHOPEDIC EDGE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERICK
Authorized Official - Middle Name:B
Authorized Official - Last Name:FOUNTAIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-761-3530
Mailing Address - Street 1:51064 FILOMENA DR
Mailing Address - Street 2:
Mailing Address - City:SHELBY TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48315-2937
Mailing Address - Country:US
Mailing Address - Phone:586-566-5116
Mailing Address - Fax:586-566-5146
Practice Address - Street 1:51064 FILOMENA DR
Practice Address - Street 2:
Practice Address - City:SHELBY TWP
Practice Address - State:MI
Practice Address - Zip Code:48315-2937
Practice Address - Country:US
Practice Address - Phone:586-566-5116
Practice Address - Fax:586-566-5146
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010159261QP2000X
MI5501010776261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy