Provider Demographics
NPI:1447443072
Name:DIVERSIFIED PHYSICAL THERAPY
Entity type:Organization
Organization Name:DIVERSIFIED PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SPRAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:231-755-4404
Mailing Address - Street 1:4358 CAROLYN ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-4468
Mailing Address - Country:US
Mailing Address - Phone:231-755-4404
Mailing Address - Fax:231-755-7704
Practice Address - Street 1:1595 W SHERMAN BLVD
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-3542
Practice Address - Country:US
Practice Address - Phone:231-755-4404
Practice Address - Fax:231-755-7704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501006200225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P16250Medicare PIN