Individual
ANDA HOLDER
Active
Sole proprietor
No
Provider details
NPI number
Gender
X
Contact information
Practice address
2020 GULL RD, KALAMAZOO, MI 49048-1515
(269) 234-2941
Mailing address
625 KENMOOR AVE SE STE 100, GRAND RAPIDS, MI 49546-2395
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
5501303974
MI
Other
Enumeration date
08/23/2025
Last updated
08/23/2025
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