Provider Demographics
NPI:1427184589
Name:INDEPENDENCE REHAB LLC
Entity Type:Organization
Organization Name:INDEPENDENCE REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:616-340-6407
Mailing Address - Street 1:3753 BASSWOOD DR SW
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2003
Mailing Address - Country:US
Mailing Address - Phone:616-340-6407
Mailing Address - Fax:616-301-2882
Practice Address - Street 1:3753 BASSWOOD DR SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2003
Practice Address - Country:US
Practice Address - Phone:616-340-6407
Practice Address - Fax:616-301-2882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-25
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005678261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P13970Medicare PIN