Basic Information
| Provider Information | |||||||||
| NPI: | 1750931861 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED LYMPHEDEMA AND REHAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 KIRKSHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | ROSCOMMON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486539221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864412222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 312 KIRKSHIRE AVE | ||||||||
| Address2: | |||||||||
| City: | ROSCOMMON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486539221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864412222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2019 | ||||||||
| LastUpdateDate: | 09/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | LANG | ||||||||
| AuthorizedOfficialFirstName: | ANDREW | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | OCCUPATIONAL THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 5864412222 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | OTRL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
No ID Information.