Healthcare Provider Details

I. General information

NPI: 1811104193
Provider Name (Legal Business Name): EAGLE P-T
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3920 S 120TH ST
GREENFIELD WI
53228-1882
US

IV. Provider business mailing address

3920 S 120TH ST
GREENFIELD WI
53228
US

V. Phone/Fax

Practice location:
  • Phone: 414-546-2667
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1436024
License Number StateWI

VIII. Authorized Official

Name: MR. DENNIS SOBUSH
Title or Position: OWNER
Credential: PT
Phone: 414-546-2667