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General NPI Number Information
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NPI Number | 1427184589
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Entity Type | Organization
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Legal Business Name | INDEPENDENCE REHAB LLC
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Dates
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Enumeration Date | 02/25/2007
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Last Update Date | 02/12/2008
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Provider Practice Location Address
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Address Line | 3753 BASSWOOD DR SW
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City | GRANDVILLE
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State | MI
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Zip | 49418-2003
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Country | US
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Telephone | 616-340-6407
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Fax | 616-301-2882
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Provider Business Mailing Address
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Address Line | 3753 BASSWOOD DR SW
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City | GRANDVILLE
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State | MI
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Zip | 49418-2003
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Country | US
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Telephone | 616-340-6407
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Fax | 616-301-2882
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Authorized Official
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Title or Position | OWNER
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Name | MR. KIRK CHRISTOPHER RANDALL
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Credential | P.T.
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Telephone | 616-340-6407
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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 | 5501005678
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License Number State | MI
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