Provider Demographics
NPI:1578176269
Name:PRO-LINE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:PRO-LINE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KALLIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-695-1000
Mailing Address - Street 1:25899 W 12 MILE RD STE 335
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-8343
Mailing Address - Country:US
Mailing Address - Phone:313-695-1000
Mailing Address - Fax:
Practice Address - Street 1:25899 W 12 MILE RD STE 335
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-8343
Practice Address - Country:US
Practice Address - Phone:313-695-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy