Basic Information
| Provider Information | |||||||||
| NPI: | 1376512020 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELITE REHAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2449 E. 12 MILE RD. | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867554711 | ||||||||
| FaxNumber: | 5867557211 | ||||||||
| Practice Location | |||||||||
| Address1: | 2449 E. 12 MILE | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867554711 | ||||||||
| FaxNumber: | 5867557211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 11/18/2009 | ||||||||
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| AuthorizedOfficialLastName: | GUSHO | ||||||||
| AuthorizedOfficialFirstName: | BETTY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 5867554711 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | L537632 | MI | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | L475728 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.