Provider Demographics
NPI:1669148029
Name:FENTON PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:FENTON PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:OTIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-629-3338
Mailing Address - Street 1:14229 TORREY RD STE 1
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3308
Mailing Address - Country:US
Mailing Address - Phone:810-629-3338
Mailing Address - Fax:
Practice Address - Street 1:14229 TORREY RD STE 2
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3308
Practice Address - Country:US
Practice Address - Phone:810-629-3338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIRT FOOT AND ANKLE SPECIALISTS P C
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy