Provider Demographics
NPI:1508027624
Name:VIBRA OF SOUTHEASTERN MICHIGAN LLC
Entity Type:Organization
Organization Name:VIBRA OF SOUTHEASTERN MICHIGAN LLC
Other - Org Name:VIBRA OF SOUTHEASTERN MICHIGAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:HOLLINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-591-5700
Mailing Address - Street 1:PO BOX 26657
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93729-6657
Mailing Address - Country:US
Mailing Address - Phone:559-892-2500
Mailing Address - Fax:559-892-2444
Practice Address - Street 1:26400 WEST OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2088
Practice Address - Country:US
Practice Address - Phone:313-594-6000
Practice Address - Fax:313-594-6252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-20
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI820130282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI302715477Medicaid
MI302715477Medicaid