Provider Demographics
NPI:1972963437
Name:PEAK PHYSICAL THERAPY CLINIC LLC
Entity Type:Organization
Organization Name:PEAK PHYSICAL THERAPY CLINIC LLC
Other - Org Name:PEAK PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:GALLEGOS
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:810-360-0806
Mailing Address - Street 1:455 E GRAND RIVER AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-1551
Mailing Address - Country:US
Mailing Address - Phone:810-360-0806
Mailing Address - Fax:810-360-0327
Practice Address - Street 1:455 E GRAND RIVER AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1551
Practice Address - Country:US
Practice Address - Phone:810-360-0806
Practice Address - Fax:810-360-0327
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501011484225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12221828OtherCAQH PROVIDER NUMBER
MIMI6211093Medicare PIN
MI12221828OtherCAQH PROVIDER NUMBER