Healthcare Provider Details

I. General information

NPI: 1295139236
Provider Name (Legal Business Name): JOSE CRESPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2014
Last Update Date: 03/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 N MILWAUKEE ST
WATERFORD WI
53185-4432
US

IV. Provider business mailing address

625 ENTERPRISE DR
OAK BROOK IL
60523-8813
US

V. Phone/Fax

Practice location:
  • Phone: 262-514-2700
  • Fax: 262-514-3003
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12810-24
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: