Provider Demographics
NPI:1912512575
Name:PARK WARREN PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:PARK WARREN PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:ALEXANDRIA
Authorized Official - Last Name:ABAZEED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-920-5522
Mailing Address - Street 1:26000 HOOVER RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-1167
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:26000 HOOVER RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1167
Practice Address - Country:US
Practice Address - Phone:313-406-4413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-10
Last Update Date:2020-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Single Specialty