Provider Demographics
NPI:1881714749
Name:ALTA SOMA PHYSICAL THERAPY
Entity type:Organization
Organization Name:ALTA SOMA PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:ABLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-369-7941
Mailing Address - Street 1:36752 LOWER LAKE RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-9447
Mailing Address - Country:US
Mailing Address - Phone:262-369-7941
Mailing Address - Fax:
Practice Address - Street 1:560 S INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-2324
Practice Address - Country:US
Practice Address - Phone:262-369-7941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2334-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty