Provider Demographics
NPI:1740481779
Name:BACK IN ACTION REHABILITATION, S.C.
Entity type:Organization
Organization Name:BACK IN ACTION REHABILITATION, S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:WUNSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-922-7776
Mailing Address - Street 1:103 S PIONEER RD # 100
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3871
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:N8218 STATE ROAD 28
Practice Address - Street 2:
Practice Address - City:MAYVILLE
Practice Address - State:WI
Practice Address - Zip Code:53050-2126
Practice Address - Country:US
Practice Address - Phone:920-387-9000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BACK IN ACTION REHABILITATION SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-29
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41220600Medicaid
WI000086583Medicare ID - Type Unspecified