Provider Demographics
NPI:1457012460
Name:ADVANTAGE PHYSICAL THERAPY & SPORTS REHAB, LLC
Entity Type:Organization
Organization Name:ADVANTAGE PHYSICAL THERAPY & SPORTS REHAB, LLC
Other - Org Name:CORA PHYSICAL THERAPY - CAPITAL DRIVE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VP
Authorized Official - Prefix:
Authorized Official - First Name:CALVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:KENNEDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-221-6717
Mailing Address - Street 1:PO BOX 150
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-0150
Mailing Address - Country:US
Mailing Address - Phone:419-221-6717
Mailing Address - Fax:419-222-0507
Practice Address - Street 1:9120 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-1622
Practice Address - Country:US
Practice Address - Phone:419-221-6717
Practice Address - Fax:419-222-0507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-03
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100192246Medicaid