Basic Information
| Provider Information | |||||||||
| NPI: | 1013520576 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WRIGHT AVENUE REHAB, PLLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WRIGHT AVENUE REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 331 E WRIGHT AVE | ||||||||
| Address2: | |||||||||
| City: | SHEPHERD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488838065 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 331 E WRIGHT AVE | ||||||||
| Address2: | |||||||||
| City: | SHEPHERD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488838065 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9895671300 | ||||||||
| FaxNumber: | 9895671301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2020 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | BLICK | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | DWAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9895671300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DPT | ||||||||
| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.