MEDICARE: LANDERS REHABILITATION SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility	AS630385934	MI
2	311ZA0620X	Adult Care Home Facility	AS630385934	MI
3	320700000X	Physical Disabilities Residential Treatment Facility	AS630385934	MI
4	261QR0400X	Rehabilitation Clinic/Center

General Provider Information

NPI Number	:	1184159030
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LANDERS REHABILITATION SERVICES LLC

Provider Business Mailing Address
First Line	:	25695 MULBERRY DR
Second Line	:	PO BOX 33202 BLOOMFIELD HILLS
City	:	SOUTHFIELD
State	:	MI
Zip	:	48033-2777
Country	:	US
Telephone Number	:	248-905-3985
Fax Number	:	248-281-3476

Provider Business Practice Location Address
First Line	:	25695 MULBERRY DR
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48033-2777
Country	:	US
Telephone Number	:	248-905-3985
Fax Number	:	248-281-3476

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. NICHOLE A LANDERS
Credential	:
Telephone Number	:	313-213-2916

Provider Enumeration Date	:	04/28/2017
Last Update Date	:	04/28/2017

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