Provider Demographics
NPI:1386937530
Name:GREAT NORTHERN REHAB P C
Entity type:Organization
Organization Name:GREAT NORTHERN REHAB P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:SHUTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-732-8868
Mailing Address - Street 1:2620 SE MARICAMP RD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-5582
Mailing Address - Country:US
Mailing Address - Phone:352-732-8868
Mailing Address - Fax:352-732-8890
Practice Address - Street 1:1310 E CLOVERLAND DR
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-1606
Practice Address - Country:US
Practice Address - Phone:906-932-4200
Practice Address - Fax:906-932-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-20
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty