Provider Demographics
NPI:1649779331
Name:JDR74 HOLDINGS, LLC
Entity Type:Organization
Organization Name:JDR74 HOLDINGS, LLC
Other - Org Name:5 STAR PHYSICAL THERAPY SPECIALISTS
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:RABORN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:517-449-7173
Mailing Address - Street 1:13060 S US HIGHWAY 27 STE C4
Mailing Address - Street 2:
Mailing Address - City:DEWITT
Mailing Address - State:MI
Mailing Address - Zip Code:48820-9319
Mailing Address - Country:US
Mailing Address - Phone:517-449-7173
Mailing Address - Fax:
Practice Address - Street 1:13060 S US HIGHWAY 27 STE C4
Practice Address - Street 2:
Practice Address - City:DEWITT
Practice Address - State:MI
Practice Address - Zip Code:48820-9319
Practice Address - Country:US
Practice Address - Phone:517-449-7173
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014355225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty