Provider Demographics
NPI:1306034772
Name:MELTON PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MELTON PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:R
Authorized Official - Last Name:MELTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:231-258-6789
Mailing Address - Street 1:1050 S OTSEGO AVE
Mailing Address - Street 2:
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-9171
Mailing Address - Country:US
Mailing Address - Phone:989-731-6781
Mailing Address - Fax:989-705-8448
Practice Address - Street 1:1050 S OTSEGO AVE
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9171
Practice Address - Country:US
Practice Address - Phone:989-731-6781
Practice Address - Fax:989-705-8448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009879225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP26101Medicare UPIN
MIN87100Medicare UPIN
MIN70040005Medicare UPIN