Provider Demographics
NPI:1174177190
Name:FAST TRACK PHYSICAL THERAPY & REHAB CENTER LLC
Entity type:Organization
Organization Name:FAST TRACK PHYSICAL THERAPY & REHAB CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARIA TERESA
Authorized Official - Middle Name:TRONGCO
Authorized Official - Last Name:BANCOLITA-COOK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:586-604-9184
Mailing Address - Street 1:43648 SCHOENHERR RD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1113
Mailing Address - Country:US
Mailing Address - Phone:248-420-3395
Mailing Address - Fax:
Practice Address - Street 1:43648 SCHOENHERR RD
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1113
Practice Address - Country:US
Practice Address - Phone:586-604-9184
Practice Address - Fax:800-679-9769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-29
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1235188343Medicaid
MI1174177190Medicaid