Provider Demographics
NPI:1023210812
Name:BODY RENOVATION HEALTH SERVICES, S.C.
Entity Type:Organization
Organization Name:BODY RENOVATION HEALTH SERVICES, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:262-375-1075
Mailing Address - Street 1:4810 UPPER FOREST BEACH RD
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53074-9715
Mailing Address - Country:US
Mailing Address - Phone:262-375-1075
Mailing Address - Fax:262-375-4975
Practice Address - Street 1:2020 CHEYENNE CT
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024
Practice Address - Country:US
Practice Address - Phone:262-375-1075
Practice Address - Fax:262-375-4975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy