Provider Demographics
NPI:1568416337
Name:CENTER FOR PHYSICAL REHABILITATION INC
Entity Type:Organization
Organization Name:CENTER FOR PHYSICAL REHABILITATION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:DISTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC
Authorized Official - Phone:616-954-0959
Mailing Address - Street 1:5060 CASCADE RD SE
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3808
Mailing Address - Country:US
Mailing Address - Phone:616-954-0950
Mailing Address - Fax:616-954-1728
Practice Address - Street 1:5060 CASCADE RD SE
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3808
Practice Address - Country:US
Practice Address - Phone:616-954-0950
Practice Address - Fax:616-954-1728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30380OtherBC/BS
MI236697Medicare ID - Type Unspecified