Provider Demographics
NPI:1578860292
Name:GENOVACARE-WISCONSIN, LLC
Entity Type:Organization
Organization Name:GENOVACARE-WISCONSIN, LLC
Other - Org Name:ICON PHYSICAL THERAPY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:TOMERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-564-0100
Mailing Address - Street 1:8575 W FOREST HOME AVE STE 50
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53228-3469
Mailing Address - Country:US
Mailing Address - Phone:414-525-9999
Mailing Address - Fax:414-525-9971
Practice Address - Street 1:8575 W FOREST HOME AVE STE 50
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53228-3469
Practice Address - Country:US
Practice Address - Phone:414-525-9999
Practice Address - Fax:414-525-9971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-15
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation