1215478763 NPI number — SPORTS PHYSICAL THERAPISTS OF RACINE LLC

Table of content: (NPI 1215478763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215478763 NPI number — SPORTS PHYSICAL THERAPISTS OF RACINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPORTS PHYSICAL THERAPISTS OF RACINE 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:
1215478763
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:
7200 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
STE D103
Provider Business Practice Location Address City Name:
MOUNT PLEASANT
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53406-6516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-583-0790
Provider Business Practice Location Address Fax Number:
262-583-0768
Provider Enumeration Date:
03/16/2017

Additional Information

Authorized Official

Authorized Official Last Name:
TENUTA
Authorized Official First Name:
CARMELO
Authorized Official Middle Name:
D
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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