Provider Demographics
NPI:1619414687
Name:REVIVE REHAB CENTER LLC
Entity Type:Organization
Organization Name:REVIVE REHAB CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-995-6788
Mailing Address - Street 1:2118 S WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48186-5428
Mailing Address - Country:US
Mailing Address - Phone:313-995-6788
Mailing Address - Fax:
Practice Address - Street 1:2118 S WAYNE RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-5428
Practice Address - Country:US
Practice Address - Phone:313-995-6788
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIPENDINGMedicare PIN