Provider Demographics
NPI:1629359369
Name:INTERSTATE REHAB INC
Entity Type:Organization
Organization Name:INTERSTATE REHAB INC
Other - Org Name:ESSENZA PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE
Authorized Official - Prefix:
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:B
Authorized Official - Last Name:CARBONELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:586-530-7114
Mailing Address - Street 1:16910 W 10 MILE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2920
Mailing Address - Country:US
Mailing Address - Phone:734-341-8068
Mailing Address - Fax:
Practice Address - Street 1:16910 W 10 MILE RD STE 101
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2920
Practice Address - Country:US
Practice Address - Phone:734-341-8068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-08
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy