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General NPI Number Information
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NPI Number | 1114929064
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Entity Type | Organization
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Legal Business Name | SOUTHPORT REHAB ASSOCIATES, INC
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Dates
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Enumeration Date | 08/11/2005
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Last Update Date | 04/10/2008
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Provider Practice Location Address
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Address Line | 7201 GREEN BAY RD
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City | KENOSHA
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State | WI
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Zip | 53142-3522
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Country | US
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Telephone | 262-694-3977
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Fax | 262-694-5648
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Provider Business Mailing Address
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Address Line | 7201 GREEN BAY RD
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City | KENOSHA
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State | WI
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Zip | 53142-3522
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Country | US
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Telephone | 262-694-3977
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Fax | 262-694-5648
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. WILLIAM H LETSOM
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Credential | P.T.
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Telephone | 262-694-3977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number |
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License Number State | WI
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