Healthcare Provider Details

I. General information

NPI: 1023338506
Provider Name (Legal Business Name): ORTHOPEDIC & SPINE THERAPY OF LAKEWOOD, SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 06/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17187 TWIN PINES RD
LAKEWOOD WI
54138-9300
US

IV. Provider business mailing address

4000 N PROVIDENCE AVE
APPLETON WI
54913-8018
US

V. Phone/Fax

Practice location:
  • Phone: 920-257-2000
  • Fax: 920-257-2004
Mailing address:
  • Phone: 920-257-2000
  • Fax: 920-257-2004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PAUL S. BARNETT
Title or Position: OWNER/PRESIDENT
Credential: P.T.
Phone: 920-257-2000