Basic Information
| Provider Information | |||||||||
| NPI: | 1831363274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAIN | ||||||||
| FirstName: | KISTUR AJITH | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3181 SANDHILL RD | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488549425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173366060 | ||||||||
| FaxNumber: | 5173366050 | ||||||||
| Practice Location | |||||||||
| Address1: | 3181 SANDHILL RD | ||||||||
| Address2: | |||||||||
| City: | MASON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488549425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173366060 | ||||||||
| FaxNumber: | 5173366050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2008 | ||||||||
| LastUpdateDate: | 04/16/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225000000X | 5501013601 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Orthotic Fitter |
No ID Information.