Provider Demographics
NPI:1881771632
Name:POUND PT CLINIC LLC
Entity type:Organization
Organization Name:POUND PT CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:SYTSMA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:920-897-4799
Mailing Address - Street 1:PO BOX 11
Mailing Address - Street 2:
Mailing Address - City:POUND
Mailing Address - State:WI
Mailing Address - Zip Code:54161
Mailing Address - Country:US
Mailing Address - Phone:920-897-4799
Mailing Address - Fax:920-897-4128
Practice Address - Street 1:3010 BUSINESS HIGHWAY 141
Practice Address - Street 2:
Practice Address - City:POUND
Practice Address - State:WI
Practice Address - Zip Code:54161
Practice Address - Country:US
Practice Address - Phone:920-897-4799
Practice Address - Fax:920-897-4128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI864024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40133900Medicaid
WI82692Medicare ID - Type Unspecified