Provider Demographics
NPI:1922250539
Name:MONDOVI PHYSICAL THERAPY,LLC
Entity Type:Organization
Organization Name:MONDOVI PHYSICAL THERAPY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:ALICE
Authorized Official - Last Name:OLSON-BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:715-926-5177
Mailing Address - Street 1:860 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MONDOVI
Mailing Address - State:WI
Mailing Address - Zip Code:54755-1458
Mailing Address - Country:US
Mailing Address - Phone:715-926-5177
Mailing Address - Fax:715-926-5137
Practice Address - Street 1:860 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MONDOVI
Practice Address - State:WI
Practice Address - Zip Code:54755-1458
Practice Address - Country:US
Practice Address - Phone:715-926-5177
Practice Address - Fax:715-926-5137
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-14
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2615-024261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy