Provider Demographics
NPI:1851014401
Name:PHYSICO PT, LLC
Entity Type:Organization
Organization Name:PHYSICO PT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KALLIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:313-314-0090
Mailing Address - Street 1:6 PARKLANE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4206
Mailing Address - Country:US
Mailing Address - Phone:313-314-0090
Mailing Address - Fax:313-314-0095
Practice Address - Street 1:6 PARKLANE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4206
Practice Address - Country:US
Practice Address - Phone:313-314-0090
Practice Address - Fax:313-314-0095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy