Basic Information
| Provider Information | |||||||||
| NPI: | 1881205045 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREESTONE | ||||||||
| FirstName: | SAMUEL | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 607 DEWEY AVE NW STE 300 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495045283 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163565000 | ||||||||
| FaxNumber: | 6163565001 | ||||||||
| Practice Location | |||||||||
| Address1: | 6016 LOVERS LN STE 3 | ||||||||
| Address2: | |||||||||
| City: | PORTAGE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490023050 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693290934 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2020 | ||||||||
| LastUpdateDate: | 08/12/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 5501019656 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.