Provider Demographics
NPI:1437823465
Name:411 PT INC
Entity Type:Organization
Organization Name:411 PT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MIRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:FAYAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-850-7888
Mailing Address - Street 1:23265 NORTHWESTERN HWY
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-7707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19201 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-3393
Practice Address - Country:US
Practice Address - Phone:248-996-9428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-03
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy