Basic Information
| Provider Information | |||||||||
| NPI: | 1851688238 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCONNELL | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 54530 COUNTY ROAD 1 | ||||||||
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| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465148961 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 5535 S WILLIAMSON BLVD | ||||||||
| Address2: | 774 | ||||||||
| City: | PORT ORANGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321288311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003307711 | ||||||||
| FaxNumber: | 8664262811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2011 | ||||||||
| LastUpdateDate: | 07/06/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 06004145A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.