Healthcare Provider Details

I. General information

NPI: 1508887464
Provider Name (Legal Business Name): OPTIMAL PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 10/23/2025
Certification Date: 10/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 ELM ST
LAKE MILLS WI
53551-1127
US

IV. Provider business mailing address

805 ELM ST
LAKE MILLS WI
53551-1127
US

V. Phone/Fax

Practice location:
  • Phone: 920-648-2400
  • Fax: 920-648-2444
Mailing address:
  • Phone: 920-648-2400
  • Fax: 920-648-2444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JULIE LARSON
Title or Position: OFFICE MANGER
Credential:
Phone: 920-648-2400