Provider Demographics
NPI:1982980751
Name:VIVID IDEA REHAB
Entity Type:Organization
Organization Name:VIVID IDEA REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEXTER
Authorized Official - Middle Name:A
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:989-239-2376
Mailing Address - Street 1:2101 W STOKER DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48604-2441
Mailing Address - Country:US
Mailing Address - Phone:989-239-2376
Mailing Address - Fax:
Practice Address - Street 1:2101 WEST STOKER DR
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48604
Practice Address - Country:US
Practice Address - Phone:989-239-2376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI453595312OtherEIN