MEDICARE: RIVERSIDE PHYSICAL THERAPY & PELVIC HEALTH, S.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1487491205
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RIVERSIDE PHYSICAL THERAPY & PELVIC HEALTH, S.C.

Provider Business Mailing Address
First Line	:	4440 HARTSTONE DR
Second Line	:
City	:	SLINGER
State	:	WI
Zip	:	53086-9034
Country	:	US
Telephone Number	:	262-627-2220
Fax Number	:	262-284-9511

Provider Business Practice Location Address
First Line	:	516 E GREEN BAY AVE
Second Line	:
City	:	SAUKVILLE
State	:	WI
Zip	:	53080-2012
Country	:	US
Telephone Number	:	262-284-9510
Fax Number	:	262-284-9511

Authorized Official
Title or Position	:	PRESIDENT/PHYSICAL THERAPIST
Name	:	DIANE MARY OTT
Credential	:	PT
Telephone Number	:	262-627-2220

Provider Enumeration Date	:	07/09/2024
Last Update Date	:	07/09/2024

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