Provider Demographics
NPI:1912918475
Name:SPORT CLINIC PHYSICAL THERAPY INC
Entity Type:Organization
Organization Name:SPORT CLINIC PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:414-351-5794
Mailing Address - Street 1:8911 N PORT WASHINGTON RD
Mailing Address - Street 2:SPORT CLINIC PHYSICAL THERAPY INC
Mailing Address - City:BAYSIDE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-1634
Mailing Address - Country:US
Mailing Address - Phone:414-351-5794
Mailing Address - Fax:414-351-2770
Practice Address - Street 1:8911 N PORT WASHINGTON RD
Practice Address - Street 2:SPORT CLINIC PHYSICAL THERAPY INC
Practice Address - City:BAYSIDE
Practice Address - State:WI
Practice Address - Zip Code:53217-1634
Practice Address - Country:US
Practice Address - Phone:414-351-5794
Practice Address - Fax:414-351-2770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40424700Medicaid
WI000080039Medicare ID - Type Unspecified
WI40424700Medicaid