Healthcare Provider Details

I. General information

NPI: 1407857790
Provider Name (Legal Business Name): ADVANCED PHYSICAL THERAPY & SPORTS MEDICINE SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 03/10/2026
Certification Date: 03/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 E ENTERPRISE AVE # 113 ADVANCED PHYSICAL THERAPY
APPLETON WI
54913-7862
US

IV. Provider business mailing address

2105 E ENTERPRISE AVE STE 113
APPLETON WI
54913-7862
US

V. Phone/Fax

Practice location:
  • Phone: 920-991-2561
  • Fax: 920-991-2563
Mailing address:
  • Phone: 920-991-2561
  • Fax: 920-991-2563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: CAMILLA MEYER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 920-393-2819