Provider Demographics
NPI:1154623833
Name:PRODIGY SPINAL REHABILIATION
Entity type:Organization
Organization Name:PRODIGY SPINAL REHABILIATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUMMER
Authorized Official - Middle Name:
Authorized Official - Last Name:FAKHOURI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:313-846-9100
Mailing Address - Street 1:6309 SCHAEFER RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2210
Mailing Address - Country:US
Mailing Address - Phone:313-846-9100
Mailing Address - Fax:313-846-9104
Practice Address - Street 1:6309 SCHAEFER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2210
Practice Address - Country:US
Practice Address - Phone:313-846-9100
Practice Address - Fax:313-846-9104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty