Healthcare Provider Details

I. General information

NPI: 1780029074
Provider Name (Legal Business Name): EZ REST RE-HAB CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 07/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25932 DEQUINDRE RD STE C
WARREN MI
48091-1071
US

IV. Provider business mailing address

25932 DEQUINDRE RD STE C
WARREN MI
48091-1071
US

V. Phone/Fax

Practice location:
  • Phone: 248-275-5221
  • Fax: 586-486-5552
Mailing address:
  • Phone: 248-275-5221
  • Fax: 586-486-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number4301039079
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501005051
License Number StateMI

VIII. Authorized Official

Name: MR. MARK WOLODKOWICZ
Title or Position: OWNER
Credential:
Phone: 248-275-5221