Provider Demographics
NPI:1811391543
Name:SOUL PHYSICAL THERAPY CENTER LLC
Entity Type:Organization
Organization Name:SOUL PHYSICAL THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAYAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-581-1155
Mailing Address - Street 1:6558 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-1701
Mailing Address - Country:US
Mailing Address - Phone:313-581-1155
Mailing Address - Fax:313-581-1144
Practice Address - Street 1:6558 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1701
Practice Address - Country:US
Practice Address - Phone:313-581-1155
Practice Address - Fax:313-581-1144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIE45732261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy