Healthcare Provider Details

I. General information

NPI: 1134556103
Provider Name (Legal Business Name): HEALTH SOURCE REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2013
Last Update Date: 10/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 E 11 MILE RD
WARREN MI
48091-1192
US

IV. Provider business mailing address

4100 E 11 MILE RD
WARREN MI
48091-1192
US

V. Phone/Fax

Practice location:
  • Phone: 586-757-2440
  • Fax: 586-757-2441
Mailing address:
  • Phone: 586-757-2440
  • Fax: 586-757-2441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. AUGUSTO DAYCO
Title or Position: DIRECTOR
Credential:
Phone: 586-757-2440