Provider Demographics
NPI:1780653352
Name:HOMOLKA, ADAM EDWIN (MPT)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:EDWIN
Last Name:HOMOLKA
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6440 FULTON ST E STE 150
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9006
Mailing Address - Country:US
Mailing Address - Phone:616-920-7264
Mailing Address - Fax:616-920-7692
Practice Address - Street 1:6440 FULTON ST E STE 150
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-9006
Practice Address - Country:US
Practice Address - Phone:616-920-7264
Practice Address - Fax:616-920-7692
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012622225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN69750029Medicare PIN