Provider Demographics
NPI:1083101117
Name:KINETIC SPORTS MEDICINE AND PERFORMANCE LLC
Entity Type:Organization
Organization Name:KINETIC SPORTS MEDICINE AND PERFORMANCE LLC
Other - Org Name:KINETIC SPORTS MEDICINE AND PERFORMANCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FALK
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT, ATC
Authorized Official - Phone:214-687-6775
Mailing Address - Street 1:N29W29682 FRANCISCAN RD
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3208
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:405 GENESEE ST
Practice Address - Street 2:
Practice Address - City:DELAFIELD
Practice Address - State:WI
Practice Address - Zip Code:53018-1814
Practice Address - Country:US
Practice Address - Phone:262-337-9331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-14
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14121-24261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy