Provider Demographics
NPI:1770768046
Name:SPINE AND SPORT PHYSICAL THERAPY OF WAUPACA LLC
Entity type:Organization
Organization Name:SPINE AND SPORT PHYSICAL THERAPY OF WAUPACA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:920-538-3670
Mailing Address - Street 1:1439 CHURCHILL ST STE 102
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-2089
Mailing Address - Country:US
Mailing Address - Phone:920-538-3670
Mailing Address - Fax:715-256-9404
Practice Address - Street 1:1439 CHURCHILL ST STE 102
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-2089
Practice Address - Country:US
Practice Address - Phone:920-538-3670
Practice Address - Fax:715-256-9404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-07
Last Update Date:2008-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty