Provider Demographics
NPI:1639661119
Name:ADVANCED PHYSICAL THERAPY & SPORTS MEDICINE SC
Entity Type:Organization
Organization Name:ADVANCED PHYSICAL THERAPY & SPORTS MEDICINE SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JENIFER
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:TILLMANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-560-1147
Mailing Address - Street 1:2105 E ENTERPRISE AVE STE 113
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-7862
Mailing Address - Country:US
Mailing Address - Phone:920-560-1083
Mailing Address - Fax:920-560-1098
Practice Address - Street 1:1931 MARINETTE AVE
Practice Address - Street 2:
Practice Address - City:MARINETTE
Practice Address - State:WI
Practice Address - Zip Code:54143-3801
Practice Address - Country:US
Practice Address - Phone:715-735-5500
Practice Address - Fax:715-735-5502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-31
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty