Healthcare Provider Details

I. General information

NPI: 1265141840
Provider Name (Legal Business Name): RESILIENCE PT & PERFORMANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 LAKE PARK RD
MENASHA WI
54952-8804
US

IV. Provider business mailing address

541 BERGHUIS DR
COMBINED LOCKS WI
54113-1600
US

V. Phone/Fax

Practice location:
  • Phone: 920-850-7622
  • Fax:
Mailing address:
  • Phone: 920-850-7622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: RYAN HOLEWINSKI
Title or Position: PHYSICAL THERAPIST
Credential:
Phone: 920-850-7622