Provider Demographics
NPI:1669663928
Name:PAIN AND INJURY REHABILITATION CLINIC
Entity Type:Organization
Organization Name:PAIN AND INJURY REHABILITATION CLINIC
Other - Org Name:PAIN AND INJURY REHABILITATION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:STADICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC CMT
Authorized Official - Phone:248-354-8180
Mailing Address - Street 1:29193 NORTHWESTERN HWY # 521
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1011
Mailing Address - Country:US
Mailing Address - Phone:248-354-8180
Mailing Address - Fax:248-354-8199
Practice Address - Street 1:28300 FRANKLIN RD STE A
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1657
Practice Address - Country:US
Practice Address - Phone:248-354-8180
Practice Address - Fax:248-354-8199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009001111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO504438Medicare UPIN