Basic Information
| Provider Information | |||||||||
| NPI: | 1508027624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VIBRA OF SOUTHEASTERN MICHIGAN LLC | ||||||||
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| OtherOrganizationName: | VIBRA OF SOUTHEASTERN MICHIGAN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 EAST RIVER PARK PLACE E #460 | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937201560 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598922500 | ||||||||
| FaxNumber: | 5598922442 | ||||||||
| Practice Location | |||||||||
| Address1: | 26400 WEST OUTER DR | ||||||||
| Address2: | |||||||||
| City: | LINCOLN PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481462088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135946000 | ||||||||
| FaxNumber: | 3135946252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2008 | ||||||||
| LastUpdateDate: | 12/14/2018 | ||||||||
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| AuthorizedOfficialLastName: | FEGAN | ||||||||
| AuthorizedOfficialFirstName: | CLINT | ||||||||
| AuthorizedOfficialMiddleName: | T. | ||||||||
| AuthorizedOfficialTitleorPosition: | SEC/TREAS | ||||||||
| AuthorizedOfficialTelephone: | 7175915700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 820130 | MI | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 302715477 | 05 | MI | MEDICAID |