=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003637505
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEAK ENDURANCE PT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2024
-----------------------------------------------------
Last Update Date | 12/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1815 JANESVILLE AVE
-----------------------------------------------------
City | FORT ATKINSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53538-2712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 608-218-4215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1205 AZTEC CT
-----------------------------------------------------
City | FORT ATKINSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53538-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SPENCER AGNEW
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 920-723-3251
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------