Provider Demographics
NPI:1922000421
Name:STAR REHAB PROF PHYSICIANS, LLC
Entity Type:Organization
Organization Name:STAR REHAB PROF PHYSICIANS, LLC
Other - Org Name:STAR REHAB, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:MARIKO
Authorized Official - Last Name:TSUHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-561-5377
Mailing Address - Street 1:PO BOX 8867
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-8867
Mailing Address - Country:US
Mailing Address - Phone:719-561-5377
Mailing Address - Fax:719-561-5378
Practice Address - Street 1:201 S MCCULLOCH BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO WEST
Practice Address - State:CO
Practice Address - Zip Code:81007-2892
Practice Address - Country:US
Practice Address - Phone:719-561-5377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-15
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO44011207Q00000X
KS31344208100000X
CO391122081P2900X
KS04-316522081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSDE2582OtherRR MEDICARE
KS200362680AMedicaid
CO53283589Medicaid
CODE2582OtherRR MEDICARE
CO53283589Medicaid
COC803160Medicare PIN