Provider Demographics
NPI:1922575976
Name:HOMETOWN SUPERIOR THERAPY LLC
Entity Type:Organization
Organization Name:HOMETOWN SUPERIOR THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATIE
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:715-209-7559
Mailing Address - Street 1:16925 BADGER RD
Mailing Address - Street 2:
Mailing Address - City:MASON
Mailing Address - State:WI
Mailing Address - Zip Code:54856-9495
Mailing Address - Country:US
Mailing Address - Phone:715-209-7559
Mailing Address - Fax:715-804-4211
Practice Address - Street 1:16925 BADGER RD
Practice Address - Street 2:
Practice Address - City:MASON
Practice Address - State:WI
Practice Address - Zip Code:54856-9495
Practice Address - Country:US
Practice Address - Phone:715-209-7559
Practice Address - Fax:715-804-4211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1780840538Medicaid