Healthcare Provider Details

I. General information

NPI: 1982901765
Provider Name (Legal Business Name): MR. RICHARD SPENNER SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2011
Last Update Date: 02/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

931 NIAGARA LN
PORT WASHINGTON WI
53074-1765
US

IV. Provider business mailing address

931 NIAGARA LN
PORT WASHINGTON WI
53074-1765
US

V. Phone/Fax

Practice location:
  • Phone: 414-333-3217
  • Fax: 888-503-3706
Mailing address:
  • Phone: 414-333-3217
  • Fax: 888-503-3706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number02-04-05-025
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: