Provider Demographics
NPI:1508485616
Name:PRIN, PAUL BABANO (PT)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:BABANO
Last Name:PRIN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3375 CARVER DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48603-2361
Mailing Address - Country:US
Mailing Address - Phone:855-624-1521
Mailing Address - Fax:
Practice Address - Street 1:2100 E REMUS RD STE B
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-8301
Practice Address - Country:US
Practice Address - Phone:989-775-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1881643385Medicaid