Basic Information
| Provider Information | |||||||||
| NPI: | 1770555674 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CARDIO PULMONARY REHAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1027 | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639021027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737789348 | ||||||||
| FaxNumber: | 5736864870 | ||||||||
| Practice Location | |||||||||
| Address1: | 2725 N WESTWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737789348 | ||||||||
| FaxNumber: | 5736864870 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | TINSLEY | ||||||||
| AuthorizedOfficialFirstName: | AUSTIN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 5736864209 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.