Healthcare Provider Details

I. General information

NPI: 1154599082
Provider Name (Legal Business Name): NEW LIFE PHYSICAL THERAPY & SPORTS MEDICINE BARABOO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2008
Last Update Date: 02/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 US HIGHWAY 12 SUITE 3
BARABOO WI
53913-9277
US

IV. Provider business mailing address

840 US HIGHWAY 12 SUITE 3
BARABOO WI
53913-9277
US

V. Phone/Fax

Practice location:
  • Phone: 608-356-2334
  • Fax: 608-356-2636
Mailing address:
  • Phone: 608-356-2334
  • Fax: 608-356-2636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberAPPLIED FOR
License Number StateWI

VIII. Authorized Official

Name: MR. BRYAN CUMMINGS
Title or Position: OWNER
Credential: PT
Phone: 608-356-2334