Provider Demographics
NPI:1780040824
Name:MACOMB PHYSICAL THERAPY & REHAB LLC
Entity Type:Organization
Organization Name:MACOMB PHYSICAL THERAPY & REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KRISITNA
Authorized Official - Middle Name:
Authorized Official - Last Name:ETANISLAO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-635-3413
Mailing Address - Street 1:14207 FORD RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3148
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14207 FORD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3148
Practice Address - Country:US
Practice Address - Phone:248-635-3413
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)