Healthcare Provider Details

I. General information

NPI: 1528220472
Provider Name (Legal Business Name): TINA RIOS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2008
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 21ST ST
PRAIRIE DU SAC WI
53578-1068
US

IV. Provider business mailing address

601 21ST ST
PRAIRIE DU SAC WI
53578-1068
US

V. Phone/Fax

Practice location:
  • Phone: 608-643-4643
  • Fax:
Mailing address:
  • Phone: 608-643-4643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number305581031
License Number StateWI

VIII. Authorized Official

Name: TINA M RIOS
Title or Position: LPN
Credential:
Phone: 608-643-4643