1760495964 NPI number — JANESVILLE PHYSICAL THERAPY AND REHAB SPECIALISTS, LLC

Table of content: (NPI 1760495964)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760495964 NPI number — JANESVILLE PHYSICAL THERAPY AND REHAB SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JANESVILLE PHYSICAL THERAPY AND REHAB SPECIALISTS, 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:
1760495964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3497
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STURTEVANT
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53177-0300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-552-2996
Provider Business Mailing Address Fax Number:
866-245-8064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4323 MILTON AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
JANESVILLE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53546-9802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-757-1840
Provider Business Practice Location Address Fax Number:
608-757-1881
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRIAND
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
877-552-2996

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5817024 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 40426900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: DP2569 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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