=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821362278
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMARY REHAB CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2012
-----------------------------------------------------
Last Update Date | 03/02/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2055 28TH ST SE STE 7
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-245-7013
-----------------------------------------------------
Fax | 616-245-7018
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2055 28TH ST SE STE 7
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49508-1582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-245-7013
-----------------------------------------------------
Fax | 616-245-7018
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. MARICARMEN RAMIREZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 616-245-7013
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------