Healthcare Provider Details

I. General information

NPI: 1699965525
Provider Name (Legal Business Name): SOUTHERN LAKES PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 10/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 S KINNICKINNIC AVE SUITE THREE
MILWAUKEE WI
53207-1364
US

IV. Provider business mailing address

2121 S KINNICKINNIC AVE STE 3
MILWAUKEE WI
53207-1368
US

V. Phone/Fax

Practice location:
  • Phone: 414-744-0707
  • Fax:
Mailing address:
  • Phone: 414-744-0707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number10406024
License Number StateWI

VIII. Authorized Official

Name: DR. WILLIAM LOIS
Title or Position: OWNER/PRESIDENT
Credential: DPT
Phone: 414-744-0707