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General NPI Number Information
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NPI Number | 1679014120
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Entity Type | Organization
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Legal Business Name | SPORTS PHYSICAL THERAPISTS OF CUDAHY LLC
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Dates
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Enumeration Date | 03/16/2017
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Last Update Date | 06/05/2020
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Provider Practice Location Address
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Address Line | 3503 E LAYTON AVE STE 100
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City | CUDAHY
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State | WI
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Zip | 53110-1408
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Country | US
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Telephone | 262-925-5000
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Fax | 262-925-5001
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Provider Business Mailing Address
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Address Line | 3921 30TH AVE STE C
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City | KENOSHA
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State | WI
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Zip | 53144-1957
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Country | US
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Telephone | 262-925-5004
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Fax | 262-925-5001
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Authorized Official
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Title or Position | PRESIDENT / CEO
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Name | CARMELO TENUTA
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Credential | PT
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Telephone | 262-925-5000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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Taxonomy #2
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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 |
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