Provider Demographics
NPI:1851748305
Name:MICHIGAN MYOTHERAPY CLINIC PLLC
Entity Type:Organization
Organization Name:MICHIGAN MYOTHERAPY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INDEPENDENT CONTRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:GLORIA
Authorized Official - Last Name:SARABIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-326-8989
Mailing Address - Street 1:1221 BRIARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-2092
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1221 BRIARWOOD DR
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-2092
Practice Address - Country:US
Practice Address - Phone:810-488-0787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-14
Last Update Date:2016-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501005929225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty