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General NPI Number Information
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NPI Number | 1427195304
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Entity Type | Organization
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Legal Business Name | FIVE CORNERS PHYSICAL THERAPY S.C.
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Dates
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Enumeration Date | 01/31/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 7269 STATE ROAD 60 SUITE 1
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City | CEDARBURG
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State | WI
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Zip | 53012-9702
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Country | US
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Telephone | 262-377-8350
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Fax | 262-377-8390
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Provider Business Mailing Address
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Address Line | 7269 STATE ROAD 60 SUITE 1
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City | CEDARBURG
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State | WI
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Zip | 53012-9702
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Country | US
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Telephone | 262-377-8350
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Fax | 262-377-8390
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. TIMOTHY JOHN PROVENCHER
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Credential | PT
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Telephone | 262-377-8350
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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 | 4146-024
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 1504-154
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License Number State | WI
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