Provider Demographics
NPI:1023072550
Name:WEST MICHIGAN REHABILITATION CENTER, INC
Entity type:Organization
Organization Name:WEST MICHIGAN REHABILITATION CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:PASUPATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:VADIVELU
Authorized Official - Suffix:I
Authorized Official - Credentials:BACHOLOR DEGREE
Authorized Official - Phone:616-249-3545
Mailing Address - Street 1:3181 PRAIRIE ST SW
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49418-2097
Mailing Address - Country:US
Mailing Address - Phone:616-249-3545
Mailing Address - Fax:616-249-3549
Practice Address - Street 1:3181 PRAIRIE ST SW
Practice Address - Street 2:SUITE 102
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2097
Practice Address - Country:US
Practice Address - Phone:616-249-3545
Practice Address - Fax:616-249-3549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005841225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P01220Medicare ID - Type UnspecifiedOUTPATIENT PT