Provider Demographics
NPI:1679185094
Name:SPORTS CLUB PHYSICAL THERAPY PLLC
Entity Type:Organization
Organization Name:SPORTS CLUB PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:OPPAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-227-9812
Mailing Address - Street 1:28634 LINCOLNVIEW DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5250
Mailing Address - Country:US
Mailing Address - Phone:248-227-9812
Mailing Address - Fax:
Practice Address - Street 1:6343 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:W BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-2206
Practice Address - Country:US
Practice Address - Phone:248-227-9812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty