1679014120 NPI number — SPORTS PHYSICAL THERAPISTS OF CUDAHY LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679014120 NPI number — SPORTS PHYSICAL THERAPISTS OF CUDAHY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS PHYSICAL THERAPISTS OF CUDAHY LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1679014120
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3921 30TH AVE STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENOSHA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53144-1957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-925-5004
Provider Business Mailing Address Fax Number:
262-925-5001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3503 E LAYTON AVE
Provider Second Line Business Practice Location Address:
STE 100
Provider Business Practice Location Address City Name:
CUDAHY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53110-1408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-925-5000
Provider Business Practice Location Address Fax Number:
262-925-5001
Provider Enumeration Date:
03/16/2017

Additional Information

Authorized Official

Authorized Official Last Name:
TENUTA
Authorized Official First Name:
CARMELO
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT / CEO
Authorized Official Telephone Number:
262-925-5000

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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