Basic Information
| Provider Information | |||||||||
| NPI: | 1497405567 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | RAEHTZ | ||||||||
| FirstName: | ZACHARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30516 | ||||||||
| Address2: | DEPT 5300 | ||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48909 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5570 WILSON AVE SW STE A | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494188867 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168551495 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2022 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 5501301846 | 01 | MI | STATE | OTHER |