Provider Demographics
NPI:1932696101
Name:ATHLETIC & THERAPEUTIC INSTITUTE OF MILWAUKEE LLC
Entity Type:Organization
Organization Name:ATHLETIC & THERAPEUTIC INSTITUTE OF MILWAUKEE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CCO
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGIVERN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-296-2222
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:2304 LINEVILLE RD STE 112
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-8805
Practice Address - Country:US
Practice Address - Phone:920-321-0351
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-13
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies