Healthcare Provider Details

I. General information

NPI: 1386186617
Provider Name (Legal Business Name): GILEAD TRAUMATIC BRAIN & BACK REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2016
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17330 NORTHLAND PARK CT STE 200
SOUTHFIELD MI
48075-4318
US

IV. Provider business mailing address

17330 NORTHLAND PARK CT STE 200A
SOUTHFIELD MI
48075-4325
US

V. Phone/Fax

Practice location:
  • Phone: 313-335-4010
  • Fax:
Mailing address:
  • Phone: 248-281-4961
  • Fax: 248-415-6289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State

VIII. Authorized Official

Name: MR. BLESSEN SAMUEL
Title or Position: CEO
Credential:
Phone: 713-391-7000