Healthcare Provider Details

I. General information

NPI: 1023210812
Provider Name (Legal Business Name): BODY RENOVATION HEALTH SERVICES, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 CHEYENNE CT
GRAFTON WI
53024
US

IV. Provider business mailing address

4810 UPPER FOREST BEACH RD
PORT WASHINGTON WI
53074-9715
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 Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RICHARD WAGNER
Title or Position: PRESIDENT
Credential: PT
Phone: 262-375-1075