Provider Demographics
NPI:1972721058
Name:PHYSICAL THERAPY AT HOME, PLLC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY AT HOME, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:HILDRETH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-933-8250
Mailing Address - Street 1:55808 NICKELBY S
Mailing Address - Street 2:
Mailing Address - City:SHELBY TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48316-1008
Mailing Address - Country:US
Mailing Address - Phone:248-933-8250
Mailing Address - Fax:248-650-0556
Practice Address - Street 1:55808 NICKELBY S
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-1008
Practice Address - Country:US
Practice Address - Phone:248-933-8250
Practice Address - Fax:248-650-0556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003709225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N95490Medicare PIN