Provider Demographics
NPI:1710981436
Name:PHYSICAL THERAPY CENTER SC
Entity Type:Organization
Organization Name:PHYSICAL THERAPY CENTER SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:K
Authorized Official - Last Name:BRANES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:715-483-9221
Mailing Address - Street 1:PO BOX 851
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-0851
Mailing Address - Country:US
Mailing Address - Phone:715-483-9221
Mailing Address - Fax:715-483-1743
Practice Address - Street 1:111 THOMPSON PKWY
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-0851
Practice Address - Country:US
Practice Address - Phone:715-483-9221
Practice Address - Fax:715-483-1743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-10
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2172024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40423600Medicaid
WI40423600Medicaid