Healthcare Provider Details

I. General information

NPI: 1629017488
Provider Name (Legal Business Name): SUPRA THERAPISTS INC DBA MED TECH OCCUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

G3259 BEECHER RD
FLINT MI
48532-3615
US

IV. Provider business mailing address

26222 TELEGRAPH RD SUITE 100
SOUTHFIELD MI
48033-5318
US

V. Phone/Fax

Practice location:
  • Phone: 810-733-3163
  • Fax:
Mailing address:
  • Phone: 248-827-7200
  • Fax: 248-827-2641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PRAKASH GANDHI
Title or Position: PRESIDENT
Credential:
Phone: 248-827-7200