Provider Demographics
NPI:1649024761
Name:ROSTKER RECREATIONAL THERAPY SERVICES LLC
Entity type:Organization
Organization Name:ROSTKER RECREATIONAL THERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:ROSTKER
Authorized Official - Suffix:
Authorized Official - Credentials:CTRS,MSA, CBIS
Authorized Official - Phone:248-910-7425
Mailing Address - Street 1:1594 BEACHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WALLED LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48390-5881
Mailing Address - Country:US
Mailing Address - Phone:248-910-7425
Mailing Address - Fax:
Practice Address - Street 1:1594 BEACHWOOD DR
Practice Address - Street 2:
Practice Address - City:WALLED LAKE
Practice Address - State:MI
Practice Address - Zip Code:48390-5881
Practice Address - Country:US
Practice Address - Phone:248-910-7425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-15
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Single Specialty