Provider Demographics
NPI:1700068590
Name:ANDRESOURCE, LLC
Entity Type:Organization
Organization Name:ANDRESOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:ANDRES
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:920-497-1515
Mailing Address - Street 1:1050 CIRCLE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5568
Mailing Address - Country:US
Mailing Address - Phone:920-497-1515
Mailing Address - Fax:920-497-1513
Practice Address - Street 1:1050 CIRCLE DR
Practice Address - Street 2:SUITE B
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54304-5568
Practice Address - Country:US
Practice Address - Phone:920-497-1515
Practice Address - Fax:920-497-1513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2011-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy