Provider Demographics
NPI:1194263731
Name:SENIOR REHAB AND FITNESS LLC
Entity type:Organization
Organization Name:SENIOR REHAB AND FITNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:906-282-1653
Mailing Address - Street 1:1820 MARYS WAY
Mailing Address - Street 2:
Mailing Address - City:KINGSFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49802-4248
Mailing Address - Country:US
Mailing Address - Phone:906-282-1653
Mailing Address - Fax:906-563-8942
Practice Address - Street 1:1820 MARYS WAY
Practice Address - Street 2:
Practice Address - City:KINGSFORD
Practice Address - State:MI
Practice Address - Zip Code:49802-4248
Practice Address - Country:US
Practice Address - Phone:906-282-1653
Practice Address - Fax:906-563-8942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-02
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMII0693Medicare Oscar/Certification