Provider Demographics
NPI:1962499855
Name:PHYSICAL THERAPY ONE, P.C.
Entity Type:Organization
Organization Name:PHYSICAL THERAPY ONE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:269-323-4300
Mailing Address - Street 1:1423 W CENTRE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-5351
Mailing Address - Country:US
Mailing Address - Phone:269-323-4300
Mailing Address - Fax:269-323-4449
Practice Address - Street 1:1423 W CENTRE AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-5351
Practice Address - Country:US
Practice Address - Phone:269-323-4300
Practice Address - Fax:269-323-4449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-05
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008230225100000X
MI5501008430225100000X
MI5501011392225100000X
MI5501011041225100000X
MI5501004752225100000X
MI5501009829225100000X
MI5501010759225100000X
MI5501013485225100000X
MI5501012189225100000X
MI5501015684225100000X
MI5501013900225100000X
MI5502000788225200000X
MI5502002365225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP93923OtherBLUE CARE NETWORK
MI30702OtherBLUE CROSS
MI64-32017OtherIBA/PHP
MI64-32017OtherIBA/PHP