Healthcare Provider Details

I. General information

NPI: 1932915030
Provider Name (Legal Business Name): MRS. CARINA LOUREA CUSUMANO-BAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5100 ROCKHILL RD
KANSAS CITY MO
64110-2446
US

IV. Provider business mailing address

1425 NE TAWNY DR
LEES SUMMIT MO
64086-5945
US

V. Phone/Fax

Practice location:
  • Phone: 816-235-1735
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number2022036976
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: