Provider Demographics
NPI:1033522354
Name:NEW LIFE PHYSICAL THERAPY & SPORTS MEDICINE
Entity Type:Organization
Organization Name:NEW LIFE PHYSICAL THERAPY & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST / COO
Authorized Official - Prefix:
Authorized Official - First Name:MARY ROSE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCIANO
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, OCS
Authorized Official - Phone:608-742-9356
Mailing Address - Street 1:2639 NEW PINERY RD STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-1110
Mailing Address - Country:US
Mailing Address - Phone:608-742-9356
Mailing Address - Fax:
Practice Address - Street 1:2639 NEW PINERY RD STE 2
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-1110
Practice Address - Country:US
Practice Address - Phone:608-742-9356
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0012676261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy