Provider Demographics
NPI:1326603036
Name:PHOENIX PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:PHOENIX PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:RESIDENT AGENT
Authorized Official - Phone:586-557-4441
Mailing Address - Street 1:45628 VAN DYKE AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48317-5366
Mailing Address - Country:US
Mailing Address - Phone:586-726-4900
Mailing Address - Fax:
Practice Address - Street 1:45628 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317-5366
Practice Address - Country:US
Practice Address - Phone:586-726-4900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI802299670OtherLARA