Provider Demographics
NPI:1467499939
Name:NEW LIFE PHYSICAL THERAPY & SPORTS MEDICINE, INC.
Entity Type:Organization
Organization Name:NEW LIFE PHYSICAL THERAPY & SPORTS MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERKOOI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:608-742-9356
Mailing Address - Street 1:2639 NEW PINERY RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-1110
Mailing Address - Country:US
Mailing Address - Phone:608-742-9356
Mailing Address - Fax:608-742-3958
Practice Address - Street 1:2639 NEW PINERY RD
Practice Address - Street 2:SUITE 2
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-1110
Practice Address - Country:US
Practice Address - Phone:608-742-9356
Practice Address - Fax:608-742-3958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40423100Medicaid