Provider Demographics
NPI:1871664243
Name:BODY RENOVATION PHYSICAL THERAPY SC
Entity Type:Organization
Organization Name:BODY RENOVATION PHYSICAL THERAPY SC
Other - Org Name:BODY RENOVATION HEALTH SERVICES SC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT CSCS VCS
Authorized Official - Phone:262-375-1075
Mailing Address - Street 1:2020 CHEYENNE CT
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-9368
Mailing Address - Country:US
Mailing Address - Phone:262-375-1075
Mailing Address - Fax:262-375-4975
Practice Address - Street 1:2020 CHEYENNE CT
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-9368
Practice Address - Country:US
Practice Address - Phone:262-375-1075
Practice Address - Fax:262-375-4975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
86125Medicare ID - Type UnspecifiedPART B