Provider Demographics
NPI:1265574305
Name:DEVINE PHYSICAL THERAPY AND REHABILITATION
Entity type:Organization
Organization Name:DEVINE PHYSICAL THERAPY AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:UCHE
Authorized Official - Middle Name:
Authorized Official - Last Name:NWAGWU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-273-7188
Mailing Address - Street 1:16820 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3703
Mailing Address - Country:US
Mailing Address - Phone:313-273-7188
Mailing Address - Fax:313-273-7228
Practice Address - Street 1:16820 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3703
Practice Address - Country:US
Practice Address - Phone:313-273-7188
Practice Address - Fax:313-273-7228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501005927225100000X
MI5201001527225X00000X
MI5201004429225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI30777OtherBCBS OF MI FACILITY ID#
MI4380561Medicaid
MI30777OtherBCBS OF MI FACILITY ID#