Provider Demographics
NPI:1952902652
Name:MICHIGAN REHAB AND PERFORMANCE, LLC
Entity Type:Organization
Organization Name:MICHIGAN REHAB AND PERFORMANCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:M
Authorized Official - Last Name:BLACKMER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:231-923-6349
Mailing Address - Street 1:1613 OAKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3139
Mailing Address - Country:US
Mailing Address - Phone:231-923-6349
Mailing Address - Fax:
Practice Address - Street 1:560 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1648
Practice Address - Country:US
Practice Address - Phone:248-773-7335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-08
Last Update Date:2020-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy