Healthcare Provider Details

I. General information

NPI: 1588132260
Provider Name (Legal Business Name): GENOA CITY FYZICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2018
Last Update Date: 11/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 ELIZABETH LN UNIT C
GENOA CITY WI
53128-2120
US

IV. Provider business mailing address

5809 ROCKY BRANCH RD
SIGNAL MOUNTAIN TN
37377-1338
US

V. Phone/Fax

Practice location:
  • Phone: 262-279-2800
  • Fax: 262-295-8799
Mailing address:
  • Phone: 847-254-1708
  • Fax: 423-269-8746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS BATSON
Title or Position: OWNER
Credential: DPT
Phone: 262-279-2800