Healthcare Provider Details

I. General information

NPI: 1942606090
Provider Name (Legal Business Name): CHILDRENS REHAB CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 N MAIN ST
DAVISON MI
48423
US

IV. Provider business mailing address

324 N MAIN ST
DAVISON MI
48423-1434
US

V. Phone/Fax

Practice location:
  • Phone: 810-836-6685
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101003983
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PATRICIA SAND
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 810-875-9186