Provider Demographics
NPI:1376053033
Name:ENCORE PREAKNESS, INC.
Entity Type:Organization
Organization Name:ENCORE PREAKNESS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUE
Authorized Official - Middle Name:E
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-974-7878
Mailing Address - Street 1:4025 TAMPA RD STE 1106
Mailing Address - Street 2:
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-3213
Mailing Address - Country:US
Mailing Address - Phone:888-974-7878
Mailing Address - Fax:727-726-1825
Practice Address - Street 1:825 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:WI
Practice Address - Zip Code:53925-1675
Practice Address - Country:US
Practice Address - Phone:920-623-2520
Practice Address - Fax:920-623-9280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-09
Last Update Date:2017-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitationGroup - Multi-Specialty