Basic Information
| Provider Information | |||||||||
| NPI: | 1871141184 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SACLA | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | JONATHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17001 17 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480382801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862867100 | ||||||||
| FaxNumber: | 5852850802 | ||||||||
| Practice Location | |||||||||
| Address1: | 17001 17 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480382801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862867100 | ||||||||
| FaxNumber: | 5862860802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2019 | ||||||||
| LastUpdateDate: | 08/29/2019 | ||||||||
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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 | 225100000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.