Healthcare Provider Details

I. General information

NPI: 1093943664
Provider Name (Legal Business Name): RENAISSANCE REHABILITATION PROFESSIONALS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2009
Last Update Date: 06/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 MEADOWCROFT LN
KALAMAZOO MI
49004-3773
US

IV. Provider business mailing address

3103 MEADOWCROFT LN
KALAMAZOO MI
49004-3773
US

V. Phone/Fax

Practice location:
  • Phone: 269-568-5683
  • Fax: 866-303-9355
Mailing address:
  • Phone: 269-568-5683
  • Fax: 866-303-9355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201006389
License Number StateMI

VIII. Authorized Official

Name: CHRISTIAN M PETROVICH
Title or Position: SOLE MBR
Credential: OTR
Phone: 269-568-5683