Provider Demographics
NPI:1922363555
Name:ADVANCE PHYSICAL THERAPY & SPORTS REHAB, LLC
Entity Type:Organization
Organization Name:ADVANCE PHYSICAL THERAPY & SPORTS REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARREN
Authorized Official - Middle Name:S
Authorized Official - Last Name:KO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
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:920-356-0122
Mailing Address - Fax:920-356-0470
Practice Address - Street 1:201 GATEWAY DR STE 300
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:WI
Practice Address - Zip Code:53916-9176
Practice Address - Country:US
Practice Address - Phone:920-356-0122
Practice Address - Fax:920-356-0470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9886024261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100028270Medicaid
3182OtherMEDICARE PTAN