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General NPI Number Information
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NPI Number | 1083222376
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Entity Type | Organization
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Legal Business Name | KSR PERFORMANCE PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 07/22/2020
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Last Update Date | 07/29/2020
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Provider Practice Location Address
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Address Line | 5070 W RAWSON AVE
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City | FRANKLIN
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State | WI
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Zip | 53132-9448
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Country | US
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Telephone | 414-377-9765
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Fax |
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Provider Business Mailing Address
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Address Line | 5070 W RAWSON AVE
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City | FRANKLIN
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State | WI
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Zip | 53132-9448
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KRISTEN RUSSO
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Credential | PT
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Telephone | 209-487-4979
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number |
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License Number State |
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