Healthcare Provider Details

I. General information

NPI: 1912918475
Provider Name (Legal Business Name): SPORT CLINIC PHYSICAL THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8911 N PORT WASHINGTON RD SPORT CLINIC PHYSICAL THERAPY INC
BAYSIDE WI
53217-1634
US

IV. Provider business mailing address

8911 N PORT WASHINGTON RD SPORT CLINIC PHYSICAL THERAPY INC
BAYSIDE WI
53217-1634
US

V. Phone/Fax

Practice location:
  • Phone: 414-351-5794
  • Fax: 414-351-2770
Mailing address:
  • Phone: 414-351-5794
  • Fax: 414-351-2770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: JOHN A HENDRICKSON
Title or Position: OWER PRESIDENT
Credential: PT
Phone: 414-351-5794