Provider Demographics
NPI:1063857100
Name:ORTHOPEDIC MEDICAL RECREATION
Entity Type:Organization
Organization Name:ORTHOPEDIC MEDICAL RECREATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:IRIS
Authorized Official - Middle Name:LENA
Authorized Official - Last Name:WINCHESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-595-8800
Mailing Address - Street 1:15600 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3068
Mailing Address - Country:US
Mailing Address - Phone:248-595-8800
Mailing Address - Fax:248-595-8517
Practice Address - Street 1:15600 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3068
Practice Address - Country:US
Practice Address - Phone:248-595-8800
Practice Address - Fax:248-595-8517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain