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General NPI Number Information
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NPI Number | 1922000421
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Entity Type | Organization
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Legal Business Name | STAR REHAB PROF PHYSICIANS, LLC
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Dates
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Enumeration Date | 08/15/2005
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Last Update Date | 08/06/2009
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Provider Practice Location Address
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Address Line | 201 S MCCULLOCH BLVD
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City | PUEBLO WEST
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State | CO
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Zip | 81007-2892
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Country | US
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Telephone | 719-561-5377
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 8867
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City | PUEBLO
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State | CO
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Zip | 81008-8867
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Country | US
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Telephone | 719-561-5377
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Fax | 719-561-5378
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Authorized Official
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Title or Position | COO
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Name | LYNDA MARIKO TSUHA
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Credential |
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Telephone | 719-561-5377
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 44011
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 31344
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License Number State | KS
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Taxonomy #3
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 04-31652
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License Number State | KS
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Taxonomy #4
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Taxonomy Code | 2081P2900X
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Taxonomy Name | Pain Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 39112
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License Number State | CO
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