1770590671 NPI number — SKYLINE PHYSICAL THERAPY, AQUATICS AND REHAB SPECIALISTS

Table of content: (NPI 1770590671)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770590671 NPI number — SKYLINE PHYSICAL THERAPY, AQUATICS AND REHAB SPECIALISTS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SKYLINE PHYSICAL THERAPY, AQUATICS AND REHAB SPECIALISTS
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:
1770590671
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:
3915 30TH AVE
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:
877-552-2996
Provider Business Mailing Address Fax Number:
262-657-7190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5761 E BROWN RD
Provider Second Line Business Practice Location Address:
SUITE 2A
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85205-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-474-3424
Provider Business Practice Location Address Fax Number:
480-984-5750
Provider Enumeration Date:
08/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WOFFINDEN
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CO OWNER
Authorized Official Telephone Number:
877-474-3424

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5823 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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