Provider Demographics
NPI:1295198505
Name:MIRACLE LOVEKNOT PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:MIRACLE LOVEKNOT PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:DOUGLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-451-0600
Mailing Address - Street 1:24800 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2319
Mailing Address - Country:US
Mailing Address - Phone:248-395-2234
Mailing Address - Fax:
Practice Address - Street 1:24800 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 2
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2319
Practice Address - Country:US
Practice Address - Phone:248-395-2234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-04
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
PENDINGMedicare PIN