Provider Demographics
NPI:1336212315
Name:1ST CHOICE PHYSICAL THERAPY CLARKSTON NOVI, LLC
Entity Type:Organization
Organization Name:1ST CHOICE PHYSICAL THERAPY CLARKSTON NOVI, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:R
Authorized Official - Last Name:KOVACEK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:313-492-4293
Mailing Address - Street 1:5330 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-1692
Mailing Address - Country:US
Mailing Address - Phone:248-623-0497
Mailing Address - Fax:
Practice Address - Street 1:5330 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-1692
Practice Address - Country:US
Practice Address - Phone:248-623-0497
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501004083225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty