Provider Demographics
NPI:1639725104
Name:WILDERNESS PERFORMANCE THERAPY & STRENGTH TRAINING, LLC.
Entity Type:Organization
Organization Name:WILDERNESS PERFORMANCE THERAPY & STRENGTH TRAINING, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WILHOIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-884-1190
Mailing Address - Street 1:1823 NESS WAY
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538-4073
Mailing Address - Country:US
Mailing Address - Phone:309-287-2509
Mailing Address - Fax:
Practice Address - Street 1:1823 NESS WAY
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538-4073
Practice Address - Country:US
Practice Address - Phone:309-287-2509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-12
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy