Basic Information
| Provider Information | |||||||||
| NPI: | 1497268460 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MUNGER PHYSICAL THERAPY OF CLINTON TOWNSHIP, PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4351 24TH AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480594506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103857405 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4351 24TH AVE STE 1 | ||||||||
| Address2: | |||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480594506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103857405 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2017 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | MUNGER | ||||||||
| AuthorizedOfficialFirstName: | MARKUS | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PT/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8103857405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MUNGER PHYSICAL THERAPY, PLC | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.