=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598935967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUNDATION PHYSICAL THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2008
-----------------------------------------------------
Last Update Date | 03/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5335 S HIDDEN DR
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53221-3241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-677-0204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5335 S HIDDEN DR
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53221-3241
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-677-0204
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PHYSICAL THERAPIST
-----------------------------------------------------
Name | MRS. CHRISTINE A SENA
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 773-677-0204
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 10268-24
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------