MEDICARE: LITTLE STROKES SWIM ACADEMY LLC

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	273Y00000X	Rehabilitation Hospital Unit

General Provider Information

NPI Number	:	1568014322
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LITTLE STROKES SWIM ACADEMY LLC

Provider Business Mailing Address
First Line	:	1029 QUINN DR
Second Line	:
City	:	WAUNAKEE
State	:	WI
Zip	:	53597-2502
Country	:	US
Telephone Number	:	608-819-0134
Fax Number	:

Provider Business Practice Location Address
First Line	:	1029 QUINN DR
Second Line	:
City	:	WAUNAKEE
State	:	WI
Zip	:	53597-2502
Country	:	US
Telephone Number	:	608-819-0134
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	WILLIAM MICHAEL TYGUM
Credential	:
Telephone Number	:	608-335-3297

Provider Enumeration Date	:	07/11/2019
Last Update Date	:	07/11/2019

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