Provider Demographics
NPI:1245732361
Name:VIVID REHAB INC
Entity type:Organization
Organization Name:VIVID REHAB INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:ATAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-707-2686
Mailing Address - Street 1:12830 FORD RD STE C
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-3350
Mailing Address - Country:US
Mailing Address - Phone:313-406-3832
Mailing Address - Fax:313-406-3716
Practice Address - Street 1:12830 FORD RD STE C
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3350
Practice Address - Country:US
Practice Address - Phone:313-406-3832
Practice Address - Fax:313-406-3716
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014578261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy