Provider Demographics
NPI:1962649871
Name:WELLNESS PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:WELLNESS PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTH
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:608-359-1737
Mailing Address - Street 1:4139 WINDMILL LN
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-4206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4539 WOODGATE DR
Practice Address - Street 2:SUITE A
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-8205
Practice Address - Country:US
Practice Address - Phone:608-359-1737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6430024261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy