Provider Demographics
NPI:1962450676
Name:PRO FITNESS & REHAB, SC
Entity Type:Organization
Organization Name:PRO FITNESS & REHAB, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:STEPHEN
Authorized Official - Last Name:MANN
Authorized Official - Suffix:III
Authorized Official - Credentials:PT
Authorized Official - Phone:262-689-8185
Mailing Address - Street 1:4685 COUNTY ROAD Y
Mailing Address - Street 2:
Mailing Address - City:SAUKVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53080-1117
Mailing Address - Country:US
Mailing Address - Phone:262-689-8185
Mailing Address - Fax:
Practice Address - Street 1:10803 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5085
Practice Address - Country:US
Practice Address - Phone:262-689-8185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2010-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1516-024261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41811500Medicaid
WI526568Medicare PIN