Provider Demographics
NPI:1437429370
Name:UNION LAKE PHYSICAL REHABILITATION, LLC
Entity Type:Organization
Organization Name:UNION LAKE PHYSICAL REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STEFAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NEDELEA
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:248-593-8677
Mailing Address - Street 1:2455 UNION LAKE RD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48382
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2455 UNION LAKE RD
Practice Address - Street 2:
Practice Address - City:COMMERCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48382
Practice Address - Country:US
Practice Address - Phone:248-242-6025
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002317208100000X
MI5501008896208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty