Provider Demographics
NPI:1902467152
Name:BLUE SKY PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BLUE SKY PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-435-6356
Mailing Address - Street 1:21600 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:ST CLR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-2242
Mailing Address - Country:US
Mailing Address - Phone:678-543-5635
Mailing Address - Fax:
Practice Address - Street 1:21600 HARPER AVE
Practice Address - Street 2:
Practice Address - City:ST CLR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2242
Practice Address - Country:US
Practice Address - Phone:678-543-5635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPENDINGMedicaid