MEDICARE: SYMMETRY PAIN & WELLNESS CENTER 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	261QP2000X	Physical Therapy Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0708835	OTHER	WI	UNITED HEALTHCARE
2	169347163655	OTHER	WI	HUMANA
3	56823050	OTHER	WI	FIRST HEALTH

General Provider Information

NPI Number	:	1972537223
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SYMMETRY PAIN & WELLNESS CENTER LLC

Provider Business Mailing Address
First Line	:	200 E RYAN RD
Second Line	:	SUITE 103
City	:	OAK CREEK
State	:	WI
Zip	:	53154-4533
Country	:	US
Telephone Number	:	414-856-1970
Fax Number	:	414-856-1974

Provider Business Practice Location Address
First Line	:	200 E RYAN RD
Second Line	:	SUITE 103
City	:	OAK CREEK
State	:	WI
Zip	:	53154-4533
Country	:	US
Telephone Number	:	414-856-1970
Fax Number	:	414-856-1974

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. SOCRATES RIVERS
Credential	:
Telephone Number	:	414-856-1970

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	04/20/2008

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