Provider Demographics
NPI:1811313612
Name:ALANS PHYSICAL THERAPY OF GRAND RAPIDS
Entity type:Organization
Organization Name:ALANS PHYSICAL THERAPY OF GRAND RAPIDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:DETTMER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:218-999-5554
Mailing Address - Street 1:111 GOLF COURSE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-3526
Mailing Address - Country:US
Mailing Address - Phone:218-999-5554
Mailing Address - Fax:218-999-7620
Practice Address - Street 1:111 GOLF COURSE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-3526
Practice Address - Country:US
Practice Address - Phone:218-999-5554
Practice Address - Fax:218-999-7620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7152261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1962479436Medicaid