Healthcare Provider Details

I. General information

NPI: 1891853933
Provider Name (Legal Business Name): BENJAMIN A QUIST DPT CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 CHEYENNE CT
GRAFTON WI
53024-0368
US

IV. Provider business mailing address

8914 W BONNIWELL
MEQUON WI
53097
US

V. Phone/Fax

Practice location:
  • Phone: 262-375-1075
  • Fax: 262-375-4975
Mailing address:
  • Phone: 414-322-5750
  • Fax: 262-241-5229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number9499024
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: