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Organization
SPORTS PHYSICAL THERAPY & REHAB SPECIALISTS, S.C.
Active
Organization
SPORTS PHYSICAL THERAPY & REHAB SPECIALISTS, S.C.
Active
Other names
ATHLETICO PHYSICAL THERAPY
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JUANA L FERNANDEZ (CREDENTIALING MANAGER)
(630) 575-1980
Entity
Organization
Contact information
Practice address
3915 30TH AVE, KENOSHA, WI 53144-1957
(262) 657-0222
(262) 657-7190
Mailing address
625 ENTERPRISE DR, OAK BROOK, IL 60523-8813
(630) 575-1980
(630) 928-5080
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
—
225X00000X
Occupational Therapist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000085940
MEDICARE
WI
01
—
000086040
MEDICARE
WI
05
—
40415400
—
WI
01
—
4919795
BCBS OF IL
IL
01
—
CG8674
RAILROAD MEDICARE NUMBER
IL
01
—
CJ6927
RAILROAD MEDICARE NUMBER
WI
01
—
WI2660
MEDICARE
WI
Enumeration date
08/31/2006
Last updated
01/11/2016
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