1851036909 NPI number — THERAPEUTIC ADVANTAGE LLC

Table of content: (NPI 1851036909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851036909 NPI number — THERAPEUTIC ADVANTAGE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERAPEUTIC ADVANTAGE 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:
1851036909
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1095
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOND DU LAC
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54936-1095
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-579-5168
Provider Business Mailing Address Fax Number:
920-479-2991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
W8645 HANNA LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OAKFIELD
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53065-9546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-979-6503
Provider Business Practice Location Address Fax Number:
920-479-2991
Provider Enumeration Date:
05/03/2022

Additional Information

Authorized Official

Authorized Official Last Name:
STREETER
Authorized Official First Name:
JODY
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICAL THERAPIST, OWNER
Authorized Official Telephone Number:
920-579-5168

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1790802684 . This is a "NPI" identifier . This identifiers is of the category "OTHER".




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