Basic Information
| Provider Information | |||||||||
| NPI: | 1306244066 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER REHABILITATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2380 CEDAR ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | HOLT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488422143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177094677 | ||||||||
| FaxNumber: | 5177985667 | ||||||||
| Practice Location | |||||||||
| Address1: | 2380 CEDAR ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | HOLT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488422143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177094677 | ||||||||
| FaxNumber: | 5177985667 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2014 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | TYLER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER/PHYSICAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 5177094677 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/03/2021 | ||||||||
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.