Provider Demographics
NPI:1972880425
Name:MODERN REHABILITATION AND FAMILY PRACTICE PC
Entity Type:Organization
Organization Name:MODERN REHABILITATION AND FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOREN
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:248-285-1656
Mailing Address - Street 1:43314 MOUND RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-2022
Mailing Address - Country:US
Mailing Address - Phone:248-285-1656
Mailing Address - Fax:
Practice Address - Street 1:4379 ROCHESTER RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-4926
Practice Address - Country:US
Practice Address - Phone:248-285-1656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty