Provider Demographics
NPI:1538400528
Name:12 MILE REHAB LLC
Entity type:Organization
Organization Name:12 MILE REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MUHAMMAD
Authorized Official - Middle Name:S
Authorized Official - Last Name:AWAISI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-968-2300
Mailing Address - Street 1:15600 W 12 MILE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15600 W 12 MILE RD
Practice Address - Street 2:SUITE A
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3068
Practice Address - Country:US
Practice Address - Phone:248-968-2300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-15
Last Update Date:2013-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty