Provider Demographics
NPI:1326491358
Name:MIPC PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MIPC PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALADJIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-727-5678
Mailing Address - Street 1:21 STRATTON PL
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1771
Mailing Address - Country:US
Mailing Address - Phone:313-727-5678
Mailing Address - Fax:313-332-1955
Practice Address - Street 1:19725 ALLEN RD BLDG 1
Practice Address - Street 2:SUITE B
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1090
Practice Address - Country:US
Practice Address - Phone:734-225-8728
Practice Address - Fax:734-225-8726
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHIGAN INTERVENTIONAL PAIN CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301077632261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy