Healthcare Provider Details

I. General information

NPI: 1447639802
Provider Name (Legal Business Name): ADVANCED MOVEMENT STUDIO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2015
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 W EDISON AVE SUITE 110
APPLETON WI
54915-1367
US

IV. Provider business mailing address

101 W EDISON AVE SUITE 110
APPLETON WI
54915-1367
US

V. Phone/Fax

Practice location:
  • Phone: 920-209-1662
  • Fax:
Mailing address:
  • Phone: 920-209-1662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number11251024
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number114539
License Number StateWI

VIII. Authorized Official

Name: MR. ANDREW M BRAUN
Title or Position: FOUNDER/OWNER
Credential: LAT, CSCS, CES
Phone: 920-209-1662