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General NPI Number Information
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NPI Number | 1851891675
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Entity Type | Organization
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Legal Business Name | SPORTS PHYSICAL THERAPY & REHAB SPECIALIST, S.C.
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Dates
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Enumeration Date | 02/19/2018
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Last Update Date | 02/19/2018
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Provider Practice Location Address
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Address Line | N112W15237 MEQUON RD STE 500
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City | GERMANTOWN
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State | WI
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Zip | 53022-3468
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Country | US
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Telephone | 414-224-7834
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Fax | 414-224-7835
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Provider Business Mailing Address
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Address Line | 600 OAKMONT LN STE 600C
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City | WESTMONT
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State | IL
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Zip | 60559-5548
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Country | US
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Telephone | 630-575-1980
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Fax | 630-928-5080
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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 | 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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Taxonomy #3
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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