Provider Demographics
NPI:1972564110
Name:STAR REHAB THERAPY LLC
Entity Type:Organization
Organization Name:STAR REHAB THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
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 1:4109 N ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2009
Practice Address - Country:US
Practice Address - Phone:719-561-5377
Practice Address - Fax:719-561-5378
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STAR PHYSICIANS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-03-29
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65971850Medicaid
CO65971850Medicaid