Provider Demographics
NPI:1336246511
Name:DIVINE REHAB LLC
Entity Type:Organization
Organization Name:DIVINE REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:HITESH
Authorized Official - Middle Name:V
Authorized Official - Last Name:KHATRI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-854-0250
Mailing Address - Street 1:3741 MCDOUGALL ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-2345
Mailing Address - Country:US
Mailing Address - Phone:313-267-1615
Mailing Address - Fax:313-579-1354
Practice Address - Street 1:3741 MCDOUGALL ST
Practice Address - Street 2:SUITE 3
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-2345
Practice Address - Country:US
Practice Address - Phone:313-267-1615
Practice Address - Fax:313-579-1354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501008375225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N 90930Medicare ID - Type UnspecifiedPHYSICAL THERAPY GROUP