Provider Demographics
NPI:1376628446
Name:WEST MICHIGAN REHABILITATION CENTER INC
Entity Type:Organization
Organization Name:WEST MICHIGAN REHABILITATION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PASUPATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:VADIVELU
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:616-855-1900
Mailing Address - Street 1:5825 POWDERHORN CT SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-9340
Mailing Address - Country:US
Mailing Address - Phone:616-855-1900
Mailing Address - Fax:616-855-0565
Practice Address - Street 1:585 36TH ST SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-4002
Practice Address - Country:US
Practice Address - Phone:616-855-1900
Practice Address - Fax:616-855-0565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005841225100000X
MI5501015732225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P01220Medicare ID - Type Unspecified