Basic Information
| Provider Information | |||||||||
| NPI: | 1093365835 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SACRED HEART REHABILITATION CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 STODDARD RD | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480622505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103922167 | ||||||||
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| Practice Location | |||||||||
| Address1: | 22256 MARINE AVE | ||||||||
| Address2: | |||||||||
| City: | EASTPOINTE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480212634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865419550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2019 | ||||||||
| LastUpdateDate: | 09/13/2019 | ||||||||
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| AuthorizedOfficialLastName: | MURRAY | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMIN ASST | ||||||||
| AuthorizedOfficialTelephone: | 8103922167 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QC1500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | SA0500499 | 05 | MI | MEDICAID |