1306863220 NPI number — THERAPY PLUS OF WISCONSIN LLC

Table of content: (NPI 1306863220)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306863220 NPI number — THERAPY PLUS OF WISCONSIN LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERAPY PLUS OF WISCONSIN 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:
1306863220
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/21/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11327
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHOREWOOD
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53211-0327
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-856-1888
Provider Business Mailing Address Fax Number:
414-272-5779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8619 S HOWELL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAK CREEK
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53154-2919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-856-1888
Provider Business Practice Location Address Fax Number:
414-272-5779
Provider Enumeration Date:
07/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FREDIANI
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
F
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
414-856-1888

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: 40440600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 40602700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41044000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 36102100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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