Provider Demographics
NPI:1255867222
Name:DYNAMIC REHAB, LLC
Entity Type:Organization
Organization Name:DYNAMIC REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:SUJIT
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-233-6467
Mailing Address - Street 1:15700 PROVIDENCE DR
Mailing Address - Street 2:400
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-3144
Mailing Address - Country:US
Mailing Address - Phone:248-233-6467
Mailing Address - Fax:248-415-6289
Practice Address - Street 1:15700 PROVIDENCE DR
Practice Address - Street 2:400
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3144
Practice Address - Country:US
Practice Address - Phone:248-233-6467
Practice Address - Fax:248-415-6289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251B00000X, 251C00000X, 261QP2000X, 332B00000X, 347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No347C00000XTransportation ServicesPrivate Vehicle