MEDICARE: VIBRA OF SOUTHEASTERN MICHIGAN LLC

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	282E00000X	Long Term Care Hospital	820130	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508027624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIBRA OF SOUTHEASTERN MICHIGAN LLC

Provider Business Mailing Address
First Line	:	PO BOX 26657
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93729-6657
Country	:	US
Telephone Number	:	559-892-2500
Fax Number	:	559-892-2444

Provider Business Practice Location Address
First Line	:	26400 WEST OUTER DR
Second Line	:
City	:	LINCOLN PARK
State	:	MI
Zip	:	48146-2088
Country	:	US
Telephone Number	:	313-594-6000
Fax Number	:	313-594-6252

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. BRAD EUGENE HOLLINGER
Credential	:
Telephone Number	:	717-591-5700

Provider Enumeration Date	:	06/20/2008
Last Update Date	:	10/10/2023

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