Provider Demographics
NPI:1932327327
Name:CLARKSTON PHYSICAL THERAPY AND REHABILITATION CENTER
Entity Type:Organization
Organization Name:CLARKSTON PHYSICAL THERAPY AND REHABILITATION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ASIF
Authorized Official - Middle Name:M
Authorized Official - Last Name:CHAUDHRY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:313-862-1419
Mailing Address - Street 1:18272 LIVERNOIS AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2773
Mailing Address - Country:US
Mailing Address - Phone:313-862-1419
Mailing Address - Fax:313-862-2476
Practice Address - Street 1:18272 LIVERNOIS AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2773
Practice Address - Country:US
Practice Address - Phone:313-862-1419
Practice Address - Fax:313-862-2476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI236761261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI236761/ 1932327327OtherOPT