Organization
HEALTH SOURCE PHYSICAL THERAPY CENTER, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JAYA P BODDU (PRESIDENT)
(517) 647-1000
Entity
Organization
Contact information
Practice address
1447 E GRAND RIVER AVE, PORTLAND, MI 48875-1631
(517) 647-1000
(517) 647-1100
Mailing address
1447 E GRAND RIVER AVE, PORTLAND, MI 48875-1631
(517) 647-1000
(517) 647-1100
Taxonomy
Speciality
Code
Description
License number
State
261QP2000X
Physical Therapy Clinic/Center
Primary
5501005495
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
10-4266217
—
MI
01
—
30472
BCN
MI
01
—
5501005495
PRIORITY HEALTH
MI
01
—
64-00030
PHP
MI
01
—
650C457010
BCBS
MI
01
—
P109760
BCN
MI
Enumeration date
08/09/2006
Last updated
12/20/2011
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