Basic Information
| Provider Information | |||||||||
| NPI: | 1780614909 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WEST MICHIGAN REHABILITATION PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1695 | ||||||||
| Address2: | |||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494221695 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163923197 | ||||||||
| FaxNumber: | 6163927959 | ||||||||
| Practice Location | |||||||||
| Address1: | 44 E 8TH ST | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | HOLLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494233575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163923197 | ||||||||
| FaxNumber: | 6163927959 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/04/2006 | ||||||||
| LastUpdateDate: | 10/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | FAZIO | ||||||||
| AuthorizedOfficialFirstName: | LEONARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6163923197 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.