Provider Demographics
NPI:1356525984
Name:CROSWELL MANUAL THERAPY, INC
Entity type:Organization
Organization Name:CROSWELL MANUAL THERAPY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:SISON
Authorized Official - Last Name:DEL ROSARIO
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:810-404-8411
Mailing Address - Street 1:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:KINDE
Mailing Address - State:MI
Mailing Address - Zip Code:48445-0004
Mailing Address - Country:US
Mailing Address - Phone:989-874-4600
Mailing Address - Fax:
Practice Address - Street 1:4990 N VAN DYKE
Practice Address - Street 2:
Practice Address - City:KINDE
Practice Address - State:MI
Practice Address - Zip Code:48445-0004
Practice Address - Country:US
Practice Address - Phone:989-874-4600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSWELL MANUAL THERAPY INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-18
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501007571225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N97200OtherMEDICARE PROVIDER NUMBER
MI650G610300OtherBCBS