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General NPI Number Information
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NPI Number | 1366792350
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Entity Type | Organization
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Legal Business Name | ATHLETICO LTD
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Dates
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Enumeration Date | 09/17/2012
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Last Update Date | 10/27/2021
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Provider Practice Location Address
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Address Line | 5708 75TH ST UNIT B
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City | KENOSHA
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State | WI
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Zip | 53142-3635
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Country | US
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Telephone | 262-697-9135
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Fax | 262-697-9175
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Provider Business Mailing Address
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Address Line | 5708 75TH ST
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City | KENOSHA
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State | WI
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Zip | 53142-3635
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Country | US
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Telephone | 262-697-9135
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Fax | 262-697-9175
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | JUANA GRANADOS
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Credential |
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Telephone | 630-575-1980
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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 | IL
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