=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356260129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WISCONSIN ATHLETIC CLUB, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/14/2026
-----------------------------------------------------
Last Update Date | 07/14/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7601 N PORT WASHINGTON RD
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53217-3128
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-228-2800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10840 W ROGERS ST
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53227-1135
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | KURT ALT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 414-228-2800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------