Basic Information
| Provider Information | |||||||||
| NPI: | 1356354930 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RELIANT REHAB SERVICE AND SUPPLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2601 MORNINGSIDE DR | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547033644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155523711 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2601 MORNINGSIDE DR | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547033644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7155523711 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 11/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | BURR | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 7155523711 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 004000004276301 | WI | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 41686600 | 05 | WI | MEDICAID |