1124016407 NPI number — OCONTO PHYSICAL THERAPY, LLC

Table of content: (NPI 1124016407)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124016407 NPI number — OCONTO PHYSICAL THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OCONTO PHYSICAL THERAPY, 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:
1124016407
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/27/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 N BROADWAY
Provider Second Line Business Mailing Address:
SUITE 3C
Provider Business Mailing Address City Name:
GREEN BAY
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54303-2702
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-437-7246
Provider Business Mailing Address Fax Number:
920-437-1511

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 N BROADWAY
Provider Second Line Business Practice Location Address:
SUITE 3C
Provider Business Practice Location Address City Name:
GREEN BAY
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54303-2702
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-437-7246
Provider Business Practice Location Address Fax Number:
920-437-1511
Provider Enumeration Date:
10/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WILLETTE
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
920-437-7246

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1934 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: 2368 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 40422000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: DA7771 . This is a "MEDICARE RR" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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