Provider Demographics
NPI:1427387497
Name:VILLAGE CENTER PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:VILLAGE CENTER PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:JAYASUNDERA
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:248-905-5180
Mailing Address - Street 1:23100 PROVIDENCE DR
Mailing Address - Street 2:SUITE 135
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3646
Mailing Address - Country:US
Mailing Address - Phone:248-905-5180
Mailing Address - Fax:
Practice Address - Street 1:23100 PROVIDENCE DR
Practice Address - Street 2:SUITE 135
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3646
Practice Address - Country:US
Practice Address - Phone:248-905-5180
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005927225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty