Healthcare Provider Details

I. General information

NPI: 1720052798
Provider Name (Legal Business Name): BACK ON TRACK PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W359N5002 BROWN ST SUITE B
OCONOMOWOC WI
53066-3366
US

IV. Provider business mailing address

1622 TALLGRASS CIRCLE
WAUKESHA WI
53188
US

V. Phone/Fax

Practice location:
  • Phone: 262-560-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. JILL JOHNSTON
Title or Position: OWNER
Credential: PT
Phone: 262-366-9340