Provider Demographics
NPI:1528220472
Name:TINA RIOS
Entity Type:Organization
Organization Name:TINA RIOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:RIOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-643-4643
Mailing Address - Street 1:601 21ST ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-1068
Mailing Address - Country:US
Mailing Address - Phone:608-643-4643
Mailing Address - Fax:
Practice Address - Street 1:601 21ST ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE DU SAC
Practice Address - State:WI
Practice Address - Zip Code:53578-1068
Practice Address - Country:US
Practice Address - Phone:608-643-4643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2008-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI305581031311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38336500Medicaid