=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750188975
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUNCTIONAL REHAB AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2025
-----------------------------------------------------
Last Update Date | 02/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 591 COOL RD SE
-----------------------------------------------------
City | KALKASKA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49646-9657
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 641-330-6210
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2066
-----------------------------------------------------
City | KALKASKA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49646-2066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TASHA DEEDS
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 641-330-6210
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------