MEDICARE: SPORTS PHYSICAL THERAPISTS OF RACINE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist
2	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1215478763
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPORTS PHYSICAL THERAPISTS OF RACINE LLC

Provider Business Mailing Address
First Line	:	3921 30TH AVE STE C
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53144-1957
Country	:	US
Telephone Number	:	262-925-5004
Fax Number	:	262-925-5001

Provider Business Practice Location Address
First Line	:	7200 WASHINGTON AVE
Second Line	:	STE D103
City	:	MOUNT PLEASANT
State	:	WI
Zip	:	53406-6516
Country	:	US
Telephone Number	:	262-583-0790
Fax Number	:	262-583-0768

Authorized Official
Title or Position	:	PRESIDENT / CEO
Name	:	CARMELO D TENUTA
Credential	:	PT
Telephone Number	:	262-925-5000

Provider Enumeration Date	:	03/16/2017
Last Update Date	:	06/05/2020

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