Healthcare Provider Details

I. General information

NPI: 1508848318
Provider Name (Legal Business Name): MARY FREE BED REHABILITATION, L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 LIVERNOIS RD
TROY MI
48083-1731
US

IV. Provider business mailing address

1845 LIVERNOIS RD
TROY MI
48083-1731
US

V. Phone/Fax

Practice location:
  • Phone: 248-362-2150
  • Fax: 248-362-1702
Mailing address:
  • Phone: 248-362-2150
  • Fax: 248-362-1702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number01686
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2251H1200X
TaxonomyHand Physical Therapist
License Number01686
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License Number01686
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number01686
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number01686
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number01686
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201002959
License Number StateMI
# 8
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number01686
License Number StateMI

VIII. Authorized Official

Name: RANDALL DENEFF
Title or Position: PRESIDENT
Credential:
Phone: 616-840-8317