| Organization Name: | SPINE AND EXTREMITY INSTITUTE OF SOUTH LYON, L.L.C. |
| NPI Number: | 1811209968 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | MATTHEW ALEXANDER BROSTROM (OWNER/DIRECTOR OF PHYSICAL THERAPY) |
| Mailing Address: | 22180 Pontiac Trail Suite E South Lyon |
| State: | MI US |
| Postal Code: | 481789097 |
| Phone Number: | 2484460155 |
| Fax Number: | 2484460177 |
| NPI Enumeration Date: | 07/06/2010 |
| NPI Last Update Date: | 07/06/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 225100000X |
| License Number: | 5501010651 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Respiratory, Developmental, Rehabilitative and Restorative Service Providers |
| Taxonomy Classification: | Physical Therapist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) Physical therapists are health care professionals who evaluate and treat people with health problems resulting from injury or disease. PT |