Provider Demographics
NPI:1093226011
Name:SPOONER PHYSICAL THERAPY & WELLNESS INC
Entity Type:Organization
Organization Name:SPOONER PHYSICAL THERAPY & WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:L
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:715-635-2518
Mailing Address - Street 1:314 SERVICE RD
Mailing Address - Street 2:
Mailing Address - City:SPOONER
Mailing Address - State:WI
Mailing Address - Zip Code:54801-6200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:314 SERVICE RD
Practice Address - Street 2:
Practice Address - City:SPOONER
Practice Address - State:WI
Practice Address - Zip Code:54801-6200
Practice Address - Country:US
Practice Address - Phone:715-635-2518
Practice Address - Fax:715-635-2672
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI11879OtherPT LICENSE