Provider Demographics
NPI:1083828255
Name:PHYSICAL THERAPY & SPORTS REHABILITATION, LLC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY & SPORTS REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:262-723-2442
Mailing Address - Street 1:58 W MARKET ST
Mailing Address - Street 2:UNIT J
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-1168
Mailing Address - Country:US
Mailing Address - Phone:262-723-2442
Mailing Address - Fax:262-723-2412
Practice Address - Street 1:58 W MARKET ST
Practice Address - Street 2:UNIT J
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-1168
Practice Address - Country:US
Practice Address - Phone:262-723-2442
Practice Address - Fax:262-723-2412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4381-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI=========012OtherBLUE CROSS BLUE SHIELD