Provider Demographics
NPI:1407244916
Name:SORUM PHYSIOTHERAPY, LLC
Entity Type:Organization
Organization Name:SORUM PHYSIOTHERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NATHANAEL
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:SORUM
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:414-429-3030
Mailing Address - Street 1:5055 S 84TH ST
Mailing Address - Street 2:
Mailing Address - City:GREENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53129-1006
Mailing Address - Country:US
Mailing Address - Phone:414-429-3030
Mailing Address - Fax:
Practice Address - Street 1:19575 JANACEK CT
Practice Address - Street 2:SUITE 103
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-7101
Practice Address - Country:US
Practice Address - Phone:414-429-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1170424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty