Provider Demographics
NPI:1780022525
Name:ADVANCE PHYSICAL THERAPY AND SPORTS REHAB, LLC
Entity Type:Organization
Organization Name:ADVANCE PHYSICAL THERAPY AND SPORTS REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-356-0122
Mailing Address - Street 1:PO BOX 775
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:WI
Mailing Address - Zip Code:53916-0775
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1626 N SPRING ST STE B
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-1283
Practice Address - Country:US
Practice Address - Phone:920-356-0122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-13
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12384-24261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy