MEDICARE: GOLDEN TRIANGLE REHAB INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	30438	OTHER	MI	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1316993835
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOLDEN TRIANGLE REHAB INC

Provider Business Mailing Address
First Line	:	28051 DEQUINDRE RD STE D
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-3016
Country	:	US
Telephone Number	:	248-733-5442
Fax Number	:	248-963-6214

Provider Business Practice Location Address
First Line	:	28051 DEQUINDRE RD STE D
Second Line	:
City	:	MADISON HEIGHTS
State	:	MI
Zip	:	48071-3016
Country	:	US
Telephone Number	:	248-733-5442
Fax Number	:	248-963-6214

Authorized Official
Title or Position	:	ADMINISTRATOR OWNER
Name	:	DINA KAMAL ASMAR
Credential	:
Telephone Number	:	619-402-7927

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	06/02/2022

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