MEDICARE: 180 DEGREE REHAB 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	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1720643059
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	180 DEGREE REHAB LLC

Provider Business Mailing Address
First Line	:	40200 GRAND RIVER AVE STE 400
Second Line	:
City	:	NOVI
State	:	MI
Zip	:	48375-2146
Country	:	US
Telephone Number	:	248-987-2855
Fax Number	:	248-957-6713

Provider Business Practice Location Address
First Line	:	40200 GRAND RIVER AVE STE 400
Second Line	:
City	:	NOVI
State	:	MI
Zip	:	48375-2146
Country	:	US
Telephone Number	:	248-987-2855
Fax Number	:	248-957-6713

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	THOMAS SYRIAC
Credential	:	PT
Telephone Number	:	248-987-2855

Provider Enumeration Date	:	05/02/2019
Last Update Date	:	05/02/2019

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