Provider Demographics
NPI:1629000799
Name:DAVENPORT & ASSOCIATES PHYSICAL THERAPY
Entity type:Organization
Organization Name:DAVENPORT & ASSOCIATES PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:ALMA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:734-483-1625
Mailing Address - Street 1:LAKE POINTE CENTER
Mailing Address - Street 2:882 S. GROVE RD. (UPPER SUITE)
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198
Mailing Address - Country:US
Mailing Address - Phone:734-483-1625
Mailing Address - Fax:
Practice Address - Street 1:882 S. GROVE RD.
Practice Address - Street 2:UPPER SUITE
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48198
Practice Address - Country:US
Practice Address - Phone:734-483-1625
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2008-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501009797320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650H114050OtherBLUE CROSS
MI0P33790Medicare PIN