Basic Information
| Provider Information | |||||||||
| NPI: | 1356966683 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MICHIGAN REHABILITATION SPECIALISTS OF FOWLERVILLE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 425 N PARK BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LAKE ORION | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483623189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486936835 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2020 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | KIRK | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7087109931 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.