Provider Demographics
NPI:1497079131
Name:SPECTRUM PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SPECTRUM PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMI
Authorized Official - Middle Name:LISA
Authorized Official - Last Name:LUNDMARK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:715-362-8825
Mailing Address - Street 1:315 S ONEIDA AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-3422
Mailing Address - Country:US
Mailing Address - Phone:715-362-8825
Mailing Address - Fax:715-362-8830
Practice Address - Street 1:315 S ONEIDA AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-3422
Practice Address - Country:US
Practice Address - Phone:715-362-8825
Practice Address - Fax:715-362-8830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-24
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2749-24261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40101500Medicaid