Healthcare Provider Details

I. General information

NPI: 1952605685
Provider Name (Legal Business Name): OTR REHABILITATION, LCC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22172 TWYCKINGHAM WAY
SOUTHFIELD MI
48034-4709
US

IV. Provider business mailing address

22172 TWYCKINGHAM WAY
SOUTHFIELD MI
48034-4709
US

V. Phone/Fax

Practice location:
  • Phone: 248-355-3644
  • Fax: 248-355-3644
Mailing address:
  • Phone: 248-355-3644
  • Fax: 248-355-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY ELLIS RATCHFORD
Title or Position: ADMINISTRATOR
Credential: O.T.R.
Phone: 248-355-3644