Provider Demographics
NPI:1518467117
Name:DY, SOLOMON BUSTAMANTE (PT)
Entity Type:Individual
Prefix:
First Name:SOLOMON
Middle Name:BUSTAMANTE
Last Name:DY
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 1:2870 CLUSTER DR APT 7
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49685-7396
Mailing Address - Country:US
Mailing Address - Phone:989-975-0623
Mailing Address - Fax:
Practice Address - Street 1:1505 E PARKDALE AVE
Practice Address - Street 2:
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-9319
Practice Address - Country:US
Practice Address - Phone:231-723-2543
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008175225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist