1003035767 NPI number — ADVANCE THERAPY CENTER INC

Table of content: SHARON ANN MACDONALD DPT (NPI 1336555622)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003035767 NPI number — ADVANCE THERAPY CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCE THERAPY CENTER INC
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:
1003035767
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3475 OMRO RD
Provider Second Line Business Mailing Address:
STE. 300
Provider Business Mailing Address City Name:
OSHKOSH
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54904-7125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-233-7177
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3475 OMRO RD
Provider Second Line Business Practice Location Address:
STE. 300
Provider Business Practice Location Address City Name:
OSHKOSH
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54904-7125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-233-7177
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KING
Authorized Official First Name:
KARLA
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
920-233-7177

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  3756-024 , 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: 41219900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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