MEDICARE: WILDERNESS PERFORMANCE THERAPY & STRENGTH TRAINING, 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	261QP2000X	Physical Therapy Clinic/Center

General Provider Information

NPI Number	:	1639725104
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILDERNESS PERFORMANCE THERAPY & STRENGTH TRAINING, LLC.

Provider Business Mailing Address
First Line	:	1823 NESS WAY
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-4073
Country	:	US
Telephone Number	:	309-287-2509
Fax Number	:

Provider Business Practice Location Address
First Line	:	1823 NESS WAY
Second Line	:
City	:	MONTGOMERY
State	:	IL
Zip	:	60538-4073
Country	:	US
Telephone Number	:	309-287-2509
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	JUSTIN WILHOIT
Credential	:
Telephone Number	:	312-884-1190

Provider Enumeration Date	:	08/12/2019
Last Update Date	:	04/28/2020

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