Healthcare Provider Details

I. General information

NPI: 1801907464
Provider Name (Legal Business Name): ATHLETIC & THERAPEUTIC INSTITUTE OF MILWAUKEE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2835 N GRANDVIEW BLVD SUITE 100
PEWAUKEE WI
53072-5531
US

IV. Provider business mailing address

790 REMINGTON BLVD.
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 262-574-5185
  • Fax: 262-574-5193
Mailing address:
  • Phone: 630-296-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: LYNN MCGIVERN
Title or Position: CHIEF COMPLIANCE OFFICER
Credential:
Phone: 630-296-2222