Provider Demographics
NPI:1003025263
Name:MOUNTAIN TOWN REHAB, INC
Entity Type:Organization
Organization Name:MOUNTAIN TOWN REHAB, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:STANSBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:989-779-2920
Mailing Address - Street 1:1106 W HIGH ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-2242
Mailing Address - Country:US
Mailing Address - Phone:989-779-2920
Mailing Address - Fax:989-772-9424
Practice Address - Street 1:1106 W HIGH ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2242
Practice Address - Country:US
Practice Address - Phone:989-779-2920
Practice Address - Fax:989-772-9424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005383225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI650C700040OtherBLUE CROSS BLUE SHEILD
MI=========OtherPPOM
MI650C700040OtherBLUE CROSS BLUE SHEILD