Healthcare Provider Details

I. General information

NPI: 1407601602
Provider Name (Legal Business Name): RENEE EIDE DPT, PT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2024
Last Update Date: 04/22/2024
Certification Date: 04/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3365 S 103RD ST
MILWAUKEE WI
53227-4161
US

IV. Provider business mailing address

3365 S 103RD ST
MILWAUKEE WI
53227-4161
US

V. Phone/Fax

Practice location:
  • Phone: 586-596-0890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number13034-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: