Provider Demographics
NPI:1558374108
Name:ELITE PHYSICAL THERAPY AND REHAB SPECIALISTS
Entity Type:Organization
Organization Name:ELITE PHYSICAL THERAPY AND REHAB SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:VANAACKEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT,DPT,OCS,CSCS
Authorized Official - Phone:920-231-5195
Mailing Address - Street 1:PO BOX 3497
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-0300
Mailing Address - Country:US
Mailing Address - Phone:877-552-2996
Mailing Address - Fax:262-898-8696
Practice Address - Street 1:300 S KOELLER ST
Practice Address - Street 2:SUITE G
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-5590
Practice Address - Country:US
Practice Address - Phone:920-231-5195
Practice Address - Fax:920-231-5196
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6434-0242251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40424800Medicaid
WI5365570001Medicare NSC
WIDG3660Medicare PIN
WI40424800Medicaid