Healthcare Provider Details

I. General information

NPI: 1356260129
Provider Name (Legal Business Name): WISCONSIN ATHLETIC CLUB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7601 N PORT WASHINGTON RD
GLENDALE WI
53217-3128
US

IV. Provider business mailing address

10840 W ROGERS ST
WEST ALLIS WI
53227-1135
US

V. Phone/Fax

Practice location:
  • Phone: 414-228-2800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: KURT ALT
Title or Position: PHYSICAL THERAPIST
Credential:
Phone: 414-228-2800