Healthcare Provider Details

I. General information

NPI: 1104986603
Provider Name (Legal Business Name): PROJECT REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 EASTERN AVE SE
GRAND RAPIDS MI
49503-4735
US

IV. Provider business mailing address

330 EASTERN AVE SE
GRAND RAPIDS MI
49503-4737
US

V. Phone/Fax

Practice location:
  • Phone: 616-776-0891
  • Fax: 616-776-9906
Mailing address:
  • Phone: 616-776-0891
  • Fax: 616-776-9906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number410014
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number410163
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number410188
License Number StateMI

VIII. Authorized Official

Name: MR. TOMMY HOUSE
Title or Position: EXECUTIVE DIRECTION OF PROJECT REHA
Credential: MSW
Phone: 616-776-0891