1760495964 NPI number — JANESVILLE PHYSICAL THERAPY AND REHAB SPECIALISTS, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760495964 NPI number — JANESVILLE PHYSICAL THERAPY AND REHAB SPECIALISTS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JANESVILLE PHYSICAL THERAPY AND REHAB SPECIALISTS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760495964
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3497
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STURTEVANT
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53177-0300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-552-2996
Provider Business Mailing Address Fax Number:
866-245-8064

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4323 MILTON AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
JANESVILLE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53546-9802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-757-1840
Provider Business Practice Location Address Fax Number:
608-757-1881
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BRIAND
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
877-552-2996

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  5817024 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 40426900 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: DP2569 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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