Healthcare Provider Details

I. General information

NPI: 1326150624
Provider Name (Legal Business Name): SPORTS PHYSICAL THERAPY & REHAB SPECIALISTS, S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 30TH AVE
KENOSHA WI
53144-1957
US

IV. Provider business mailing address

625 ENTERPRISE DR
OAK BROOK IL
60523-8813
US

V. Phone/Fax

Practice location:
  • Phone: 262-657-0222
  • Fax: 262-657-7190
Mailing address:
  • Phone: 630-575-1980
  • Fax: 630-928-5080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. JUANA L FERNANDEZ
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 630-575-1980