Provider Demographics
NPI:1528013588
Name:OPTIMAL REHAB AND WELLNESS, INC
Entity Type:Organization
Organization Name:OPTIMAL REHAB AND WELLNESS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:FATE
Authorized Official - Suffix:
Authorized Official - Credentials:MS,PT
Authorized Official - Phone:269-978-6990
Mailing Address - Street 1:6568 BELA AVE
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-6599
Mailing Address - Country:US
Mailing Address - Phone:269-978-6990
Mailing Address - Fax:269-978-8283
Practice Address - Street 1:5749 STADIUM DR
Practice Address - Street 2:HOPEWOODS
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1946
Practice Address - Country:US
Practice Address - Phone:269-873-3000
Practice Address - Fax:269-978-8283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55501001115225100000X
MI55010091792251G0304X
MI5201003557225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Not Answered2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Single Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP29310Medicare ID - Type UnspecifiedGROUP PART B PROVIDER #