Provider Demographics
NPI:1942817853
Name:LAKE ORION CENTER FOR PELVIC REHABILITATION
Entity Type:Organization
Organization Name:LAKE ORION CENTER FOR PELVIC REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST, CLINIC OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:248-972-5088
Mailing Address - Street 1:4405 S BALDWIN RD STE E
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48359-2164
Mailing Address - Country:US
Mailing Address - Phone:248-972-5088
Mailing Address - Fax:888-521-1825
Practice Address - Street 1:4405 S BALDWIN RD STE E
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48359-2164
Practice Address - Country:US
Practice Address - Phone:248-972-5088
Practice Address - Fax:888-521-1825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-24
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty