Provider Demographics
NPI:1871675447
Name:DEQUINDRE PHYSICAL THERAPY & REHAB SERVICE INC.
Entity Type:Organization
Organization Name:DEQUINDRE PHYSICAL THERAPY & REHAB SERVICE INC.
Other - Org Name:DEQUINDRE PHYSICAL THERAPY & REHAB SERVICE INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARKUS
Authorized Official - Middle Name:M
Authorized Official - Last Name:MUNGER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-879-9400
Mailing Address - Street 1:41069 DEQUINDRE ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-6730
Mailing Address - Country:US
Mailing Address - Phone:248-879-9400
Mailing Address - Fax:248-879-2348
Practice Address - Street 1:41069 DEQUINDRE ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-6730
Practice Address - Country:US
Practice Address - Phone:248-879-9400
Practice Address - Fax:248-879-2348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-20
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30454OtherBCBSM
WI236587Medicare Oscar/Certification
WI236587Medicare PIN
MI236587Medicare Oscar/Certification