Provider Demographics
NPI:1508318296
Name:ENDURANCE REHABILITATION & ATHLETICS PLLC
Entity Type:Organization
Organization Name:ENDURANCE REHABILITATION & ATHLETICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:HOMOLKA
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:616-307-9950
Mailing Address - Street 1:6440 FULTON ST E
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-8449
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6440 FULTON ST E
Practice Address - Street 2:SUITE 150
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-8449
Practice Address - Country:US
Practice Address - Phone:616-307-9950
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012622225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty