Provider Demographics
NPI:1598903759
Name:PT 360 PHYSICAL THERAPY, PLC
Entity Type:Organization
Organization Name:PT 360 PHYSICAL THERAPY, PLC
Other - Org Name:PT 360
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:ASSELIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:616-776-7771
Mailing Address - Street 1:P O BOX 6088
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49516
Mailing Address - Country:US
Mailing Address - Phone:616-776-7771
Mailing Address - Fax:
Practice Address - Street 1:1502 WEALTHY ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506
Practice Address - Country:US
Practice Address - Phone:616-776-7771
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-27
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013640225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty