1104497015 NPI number — ADVANTAGE PHYSICAL THERAPY & SPORTS REHAB, LLC

Table of content: (NPI 1104497015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104497015 NPI number — ADVANTAGE PHYSICAL THERAPY & SPORTS REHAB, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANTAGE PHYSICAL THERAPY & SPORTS REHAB, 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:
6
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:
1104497015
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/27/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 150
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIMA
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45802-0150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-221-6717
Provider Business Mailing Address Fax Number:
419-222-0507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9809 39TH AVE STE 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLEASANT PRAIRIE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53158-3733
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-925-5080
Provider Business Practice Location Address Fax Number:
262-925-5081
Provider Enumeration Date:
07/02/2021

Additional Information

Authorized Official

Authorized Official Last Name:
KRZYMINSKI
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXEC. VP
Authorized Official Telephone Number:
419-221-6717

Provider Taxonomy Codes

  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100217225 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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