Provider Demographics
NPI:1306288931
Name:CUSTOM REHAB SOLUTION INC
Entity type:Organization
Organization Name:CUSTOM REHAB SOLUTION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:HETHERWIXK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-945-4980
Mailing Address - Street 1:8250 LOCKERBIE RD
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:MI
Mailing Address - Zip Code:49269-9335
Mailing Address - Country:US
Mailing Address - Phone:517-945-4980
Mailing Address - Fax:
Practice Address - Street 1:8250 LOCKERBIE RD
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:MI
Practice Address - Zip Code:49269-9335
Practice Address - Country:US
Practice Address - Phone:517-945-4980
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2014-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI55010061932251E1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251E1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistElectrophysiology, ClinicalGroup - Single Specialty