Provider Demographics
NPI:1205965340
Name:CARDIO PULMONARY REHABILITATION OF CLINTON TWP, PLLC
Entity type:Organization
Organization Name:CARDIO PULMONARY REHABILITATION OF CLINTON TWP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEFEO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-286-2350
Mailing Address - Street 1:15930 19 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1155
Mailing Address - Country:US
Mailing Address - Phone:586-286-2350
Mailing Address - Fax:
Practice Address - Street 1:15930 19 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1155
Practice Address - Country:US
Practice Address - Phone:586-286-2350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0404XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Cardiac Facilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P10840Medicare ID - Type Unspecified