Provider Demographics
NPI:1235516949
Name:EASTSIDE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:EASTSIDE PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMI
Authorized Official - Middle Name:
Authorized Official - Last Name:FALTAS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-739-9059
Mailing Address - Street 1:11258 REGAL DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-4974
Mailing Address - Country:US
Mailing Address - Phone:248-739-9059
Mailing Address - Fax:
Practice Address - Street 1:24025 GREATER MACK AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1484
Practice Address - Country:US
Practice Address - Phone:248-739-9059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-01
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008309208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty