Provider Demographics
NPI:1952605685
Name:OTR REHABILITATION, LCC
Entity Type:Organization
Organization Name:OTR REHABILITATION, LCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ELLIS
Authorized Official - Last Name:RATCHFORD
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:248-355-3644
Mailing Address - Street 1:22172 TWYCKINGHAM WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-4709
Mailing Address - Country:US
Mailing Address - Phone:248-355-3644
Mailing Address - Fax:248-355-3644
Practice Address - Street 1:22172 TWYCKINGHAM WAY
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-4709
Practice Address - Country:US
Practice Address - Phone:248-355-3644
Practice Address - Fax:248-355-3644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-10
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health