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General NPI Number Information
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NPI Number | 1245732361
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Entity Type | Organization
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Legal Business Name | VIVID REHAB INC
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Dates
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Enumeration Date | 03/05/2018
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Last Update Date | 03/05/2018
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Provider Practice Location Address
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Address Line | 12830 FORD RD STE C
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City | DEARBORN
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State | MI
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Zip | 48126-3350
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Country | US
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Telephone | 313-406-3832
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Fax | 313-406-3716
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Provider Business Mailing Address
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Address Line | 12830 FORD RD STE C
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City | DEARBORN
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State | MI
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Zip | 48126-3350
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Country | US
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Telephone | 313-406-3832
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Fax | 313-406-3716
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Authorized Official
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Title or Position | OWNER
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Name | LAWRENCE ATAT
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Credential |
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Telephone | 313-707-2686
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number | 5501014578
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License Number State | MI
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