Provider Demographics
NPI:1811015548
Name:IN HOME REHAB OF DICKINSON COUNTY
Entity Type:Organization
Organization Name:IN HOME REHAB OF DICKINSON COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-563-8920
Mailing Address - Street 1:W3101 RIDGECREST RD.
Mailing Address - Street 2:
Mailing Address - City:VULCAN
Mailing Address - State:MI
Mailing Address - Zip Code:49892
Mailing Address - Country:US
Mailing Address - Phone:906-563-8920
Mailing Address - Fax:
Practice Address - Street 1:N19748 TIMM'S LAKE ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:NIAGARA
Practice Address - State:WI
Practice Address - Zip Code:54151
Practice Address - Country:US
Practice Address - Phone:906-563-8920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501003532225100000X
MI5201002404225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty