Healthcare Provider Details

I. General information

NPI: 1770555674
Provider Name (Legal Business Name): CARDIO PULMONARY REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2725 N WESTWOOD BLVD
POPLAR BLUFF MO
63901
US

IV. Provider business mailing address

PO BOX 1027
POPLAR BLUFF MO
63902-1027
US

V. Phone/Fax

Practice location:
  • Phone: 573-778-9348
  • Fax: 573-686-4870
Mailing address:
  • Phone: 573-778-9348
  • Fax: 573-686-4870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: AUSTIN T TINSLEY
Title or Position: PARTNER
Credential: PT
Phone: 573-686-4209