Healthcare Provider Details

I. General information

NPI: 1871664243
Provider Name (Legal Business Name): BODY RENOVATION PHYSICAL THERAPY SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 CHEYENNE CT
GRAFTON WI
53024-9368
US

IV. Provider business mailing address

2020 CHEYENNE CT
GRAFTON WI
53024-9368
US

V. Phone/Fax

Practice location:
  • Phone: 262-375-1075
  • Fax: 262-375-4975
Mailing address:
  • Phone: 262-375-1075
  • Fax: 262-375-4975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. RICHARD D WAGNER JR.
Title or Position: PARTNER
Credential: PT CSCS VCS
Phone: 262-375-1075