Provider Demographics
NPI:1669655296
Name:WESTON PHYSICAL THERAPY AND SPORTS REHAB, LLC
Entity Type:Organization
Organization Name:WESTON PHYSICAL THERAPY AND SPORTS REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ELROY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KOSKEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:715-241-9331
Mailing Address - Street 1:4203 SCHOFIELD AVE
Mailing Address - Street 2:SUITE 9
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-2708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4203 SCHOFIELD AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-2708
Practice Address - Country:US
Practice Address - Phone:715-241-9331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5964-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty