Basic Information
Provider Information
NPI: 1871677294
EntityType: 2
ReplacementNPI:  
OrganizationName: ACHIEVE PHYSICAL THERAPY AND SPORTS REHAB, LLC
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Mailing Information
Address1: 2911 KNAPP ST NE
Address2: SUITE C
City: GRAND RAPIDS
State: MI
PostalCode: 495254600
CountryCode: US
TelephoneNumber: 6169759078
FaxNumber:  
Practice Location
Address1: 2911 KNAPP ST NE
Address2: SUITE C
City: GRAND RAPIDS
State: MI
PostalCode: 495254600
CountryCode: US
TelephoneNumber: 6169759078
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/24/2006
LastUpdateDate: 09/29/2008
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AuthorizedOfficialLastName: BRODERICK
AuthorizedOfficialFirstName: JEROME
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AuthorizedOfficialTitleorPosition: P.T. , OWNER
AuthorizedOfficialTelephone: 6169759078
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IsOrganizationSubpart: N
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AuthorizedOfficialCredential: P.T.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
225100000X  Y193400000X SINGLE SPECIALTY GROUPRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist 

No ID Information.


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