Provider Demographics
NPI:1114929064
Name:SOUTHPORT REHAB ASSOCIATES, INC
Entity Type:Organization
Organization Name:SOUTHPORT REHAB ASSOCIATES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:LETSOM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:262-694-3977
Mailing Address - Street 1:7201 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-3522
Mailing Address - Country:US
Mailing Address - Phone:262-694-3977
Mailing Address - Fax:262-694-5648
Practice Address - Street 1:7201 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3522
Practice Address - Country:US
Practice Address - Phone:262-694-3977
Practice Address - Fax:262-694-5648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2008-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41695100Medicaid
WI41811000Medicaid
WI41811000Medicaid