Provider Demographics
NPI:1962832402
Name:VARDUNNY, DAVIS (PTA)
Entity Type:Individual
Prefix:
First Name:DAVIS
Middle Name:
Last Name:VARDUNNY
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24217 GRAND TRAVERSE AVE
Mailing Address - Street 2:
Mailing Address - City:FLAT ROCK
Mailing Address - State:MI
Mailing Address - Zip Code:48134-8051
Mailing Address - Country:US
Mailing Address - Phone:248-552-3740
Mailing Address - Fax:248-552-3744
Practice Address - Street 1:18535 W 12 MILE RD
Practice Address - Street 2:SUITE B
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-2676
Practice Address - Country:US
Practice Address - Phone:248-552-3740
Practice Address - Fax:248-552-3744
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-20
Last Update Date:2013-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502000088261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy