Provider Demographics
NPI:1790453322
Name:FOUNDATION MANUAL PHYSICAL THERAPY AND PERFORMANCE PLLC
Entity Type:Organization
Organization Name:FOUNDATION MANUAL PHYSICAL THERAPY AND PERFORMANCE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:586-615-8585
Mailing Address - Street 1:1756 HUNTINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1916
Mailing Address - Country:US
Mailing Address - Phone:586-615-8585
Mailing Address - Fax:
Practice Address - Street 1:120 CATALPA DR
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48067-1242
Practice Address - Country:US
Practice Address - Phone:586-615-8585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy