Basic Information
Provider Information | |||||||||
NPI: | 1235510546 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TOTAL RESPIRATORY AND REHAB, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5950 S 118TH CIR | ||||||||
Address2: |   | ||||||||
City: | OMAHA | ||||||||
State: | NE | ||||||||
PostalCode: | 681374426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4029330400 | ||||||||
FaxNumber: | 4029338400 | ||||||||
Practice Location | |||||||||
Address1: | 166 JACKSON ST | ||||||||
Address2: |   | ||||||||
City: | CAMDENTON | ||||||||
State: | MO | ||||||||
PostalCode: | 650208906 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4029330400 | ||||||||
FaxNumber: | 4029338400 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2015 | ||||||||
LastUpdateDate: | 06/17/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GOODLETT | ||||||||
AuthorizedOfficialFirstName: | TIM | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER, AO | ||||||||
AuthorizedOfficialTelephone: | 4022814443 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TOTAL RESPIRATORY AND REHAB, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X |   | MO | N |   | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |   | 332B00000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies |   |
No ID Information.