Provider Demographics
NPI:1548574734
Name:LEGACY PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:LEGACY PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOWZYNSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:414-940-2978
Mailing Address - Street 1:1420 CAROLINE DR
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-7317
Mailing Address - Country:US
Mailing Address - Phone:414-940-2978
Mailing Address - Fax:
Practice Address - Street 1:1420 CAROLINE DR
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-7317
Practice Address - Country:US
Practice Address - Phone:414-940-2978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-30
Last Update Date:2010-07-30
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