Provider Demographics
NPI:1093943664
Name:RENAISSANCE REHABILITATION PROFESSIONALS LLC
Entity Type:Organization
Organization Name:RENAISSANCE REHABILITATION PROFESSIONALS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MBR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETROVICH
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:269-568-5683
Mailing Address - Street 1:3103 MEADOWCROFT LN
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49004-3773
Mailing Address - Country:US
Mailing Address - Phone:269-568-5683
Mailing Address - Fax:866-303-9355
Practice Address - Street 1:3103 MEADOWCROFT LN
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49004-3773
Practice Address - Country:US
Practice Address - Phone:269-568-5683
Practice Address - Fax:866-303-9355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201006389225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty