Provider Demographics
NPI:1497193684
Name:KACKMEISTER, THOMAS C (PTA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:C
Last Name:KACKMEISTER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 OAKMONT DR
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-9102
Mailing Address - Country:US
Mailing Address - Phone:734-224-0442
Mailing Address - Fax:
Practice Address - Street 1:10909 HANNAN RD
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-1383
Practice Address - Country:US
Practice Address - Phone:734-893-1000
Practice Address - Fax:734-941-7522
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-10
Last Update Date:2013-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502002145225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant