Provider Demographics
NPI:1427196765
Name:KEYSTONE PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:KEYSTONE PHYSICAL THERAPY LLC
Other - Org Name:KRC THERAPY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-790-5775
Mailing Address - Street 1:17045 W CAPITOL DRIVE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005
Mailing Address - Country:US
Mailing Address - Phone:262-790-5775
Mailing Address - Fax:262-790-5710
Practice Address - Street 1:17045 W CAPITOL DRIVE
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005
Practice Address - Country:US
Practice Address - Phone:262-790-5775
Practice Address - Fax:262-790-5710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
392031168010OtherANTHEM BCBS
=========010OtherANTHEM BCBS