Provider Demographics
NPI:1144351404
Name:QUALITY RECREATION & REHABILITATION
Entity type:Organization
Organization Name:QUALITY RECREATION & REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-874-3129
Mailing Address - Street 1:2641 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-1234
Mailing Address - Country:US
Mailing Address - Phone:313-874-3129
Mailing Address - Fax:248-354-3901
Practice Address - Street 1:2641 W. GRAND BLVD.
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-874-3129
Practice Address - Fax:248-354-3901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAH051664207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104662210Medicaid
MI110H222590OtherBLUE CROSS BLUE SHIELD
MI104662210Medicaid