Provider Demographics
NPI:1891706172
Name:RELIANT REHAB SERVICE AND SUPPLY
Entity Type:Organization
Organization Name:RELIANT REHAB SERVICE AND SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BURR
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:715-384-5425
Mailing Address - Street 1:1517 N OAK AVE
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-1301
Mailing Address - Country:US
Mailing Address - Phone:715-384-5425
Mailing Address - Fax:
Practice Address - Street 1:1517 N OAK AVE
Practice Address - Street 2:
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-1301
Practice Address - Country:US
Practice Address - Phone:715-384-5425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI004000004276301332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41669300Medicaid
WI0551700001Medicare ID - Type Unspecified