Provider Demographics
NPI:1396356176
Name:SPECIALIZED PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SPECIALIZED PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KISHORE
Authorized Official - Middle Name:
Authorized Official - Last Name:JEEVANANDAM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:313-414-1042
Mailing Address - Street 1:49783 ANNANDALE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2159
Mailing Address - Country:US
Mailing Address - Phone:313-414-1042
Mailing Address - Fax:
Practice Address - Street 1:49783 ANNANDALE DR
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2159
Practice Address - Country:US
Practice Address - Phone:313-414-1042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-13
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1740578095OtherNPI- IND
1063981421OtherNPI- IND