Provider Demographics
NPI:1811209968
Name:SPINE AND EXTREMITY INSTITUTE OF SOUTH LYON, L.L.C.
Entity type:Organization
Organization Name:SPINE AND EXTREMITY INSTITUTE OF SOUTH LYON, L.L.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR OF PHYSICAL THERAPY
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:BROSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:MPT, CERT MDT
Authorized Official - Phone:248-446-0155
Mailing Address - Street 1:22180 PONTIAC TRAIL
Mailing Address - Street 2:SUITE E
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-9097
Mailing Address - Country:US
Mailing Address - Phone:248-446-0155
Mailing Address - Fax:248-446-0177
Practice Address - Street 1:22180 PONTIAC TRAIL
Practice Address - Street 2:SUITE E
Practice Address - City:SOUTH LYON
Practice Address - State:MI
Practice Address - Zip Code:48178-9097
Practice Address - Country:US
Practice Address - Phone:248-446-0155
Practice Address - Fax:248-446-0177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010651225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty