Provider Demographics
NPI:1801149695
Name:MICHIGAN ORTHOPEDIC REHABILITATION LLC
Entity type:Organization
Organization Name:MICHIGAN ORTHOPEDIC REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:FUQUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-566-3525
Mailing Address - Street 1:4401 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6516
Mailing Address - Country:US
Mailing Address - Phone:248-566-3525
Mailing Address - Fax:248-566-3527
Practice Address - Street 1:4401 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6516
Practice Address - Country:US
Practice Address - Phone:248-566-3525
Practice Address - Fax:248-566-3527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-18
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty