Provider Demographics
NPI:1003035767
Name:ADVANCE THERAPY CENTER INC
Entity Type:Organization
Organization Name:ADVANCE THERAPY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KARLA
Authorized Official - Middle Name:J
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-233-7177
Mailing Address - Street 1:3475 OMRO RD
Mailing Address - Street 2:STE. 300
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54904-7125
Mailing Address - Country:US
Mailing Address - Phone:920-233-7177
Mailing Address - Fax:
Practice Address - Street 1:3475 OMRO RD
Practice Address - Street 2:STE. 300
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54904-7125
Practice Address - Country:US
Practice Address - Phone:920-233-7177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3756-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41219900Medicaid