=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811104193
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAGLE P-T
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 06/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3920 S 120TH ST
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53228-1882
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-546-2667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3920 S 120TH ST
-----------------------------------------------------
City | GREENFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DENNIS SOBUSH
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 414-546-2667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1436024
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------