MEDICARE: BACK-IN-ACTION PHYSICAL THERAPY CENTER OF KENOSHA, LTD.

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	6483024	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3907B3699000	OTHER		BCBS OF WI

General Provider Information

NPI Number	:	1801882451
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK-IN-ACTION PHYSICAL THERAPY CENTER OF KENOSHA, LTD.

Provider Business Mailing Address
First Line	:	PO BOX 158
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53141-0158
Country	:	US
Telephone Number	:	262-653-9208
Fax Number	:	262-653-9264

Provider Business Practice Location Address
First Line	:	6123 GREEN BAY RD
Second Line	:	STE 140
City	:	KENOSHA
State	:	WI
Zip	:	53142-2927
Country	:	US
Telephone Number	:	262-564-8334
Fax Number	:	262-653-9264

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	MRS. KIMBERLY DENISE SOLECKI
Credential	:
Telephone Number	:	262-925-9000

Provider Enumeration Date	:	09/20/2005
Last Update Date	:	08/22/2020

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