MEDICARE: ADVANTAGE PT & SPORTS REHAB 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	261QR0400X	Rehabilitation Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922769983
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ADVANTAGE PT & SPORTS REHAB LLC

Provider Business Mailing Address
First Line	:	PO BOX 150
Second Line	:
City	:	LIMA
State	:	OH
Zip	:	45802-0150
Country	:	US
Telephone Number	:	419-221-6717
Fax Number	:	419-222-0507

Provider Business Practice Location Address
First Line	:	2578 N MARTIN LUTHER KING DR
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53212-2710
Country	:	US
Telephone Number	:	414-529-7375
Fax Number	:

Authorized Official
Title or Position	:	EXEC VP
Name	:	STEVE KRZYMINSKI
Credential	:
Telephone Number	:	419-221-6717

Provider Enumeration Date	:	01/03/2022
Last Update Date	:	02/27/2024

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