Provider Demographics
NPI:1427195304
Name:FIVE CORNERS PHYSICAL THERAPY S.C.
Entity Type:Organization
Organization Name:FIVE CORNERS PHYSICAL THERAPY S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:PROVENCHER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:262-377-8350
Mailing Address - Street 1:7269 STATE ROAD 60
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CEDARBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53012-9702
Mailing Address - Country:US
Mailing Address - Phone:262-377-8350
Mailing Address - Fax:262-377-8390
Practice Address - Street 1:7269 STATE ROAD 60
Practice Address - Street 2:SUITE 1
Practice Address - City:CEDARBURG
Practice Address - State:WI
Practice Address - Zip Code:53012-9702
Practice Address - Country:US
Practice Address - Phone:262-377-8350
Practice Address - Fax:262-377-8390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4146-024225100000X
WI1504-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40302100Medicaid
WI=========-017OtherANTHEM BLUE CROSS BLUE SH