Provider Demographics
NPI:1689779902
Name:BALISTRERI & ASSOCIATES PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BALISTRERI & ASSOCIATES PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR ACCOUNT ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BALISTRERI-RODEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-942-0163
Mailing Address - Street 1:6926 39TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142
Mailing Address - Country:US
Mailing Address - Phone:262-942-0163
Mailing Address - Fax:262-697-1576
Practice Address - Street 1:902 WELLS STREET
Practice Address - Street 2:
Practice Address - City:LAKE GENEVA
Practice Address - State:WI
Practice Address - Zip Code:53147
Practice Address - Country:US
Practice Address - Phone:262-249-1915
Practice Address - Fax:262-249-1397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty