Organization
GREAT LAKES PHYSICAL THERAPY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. JOE E MOORE P.T (OWNER)
(920) 208-3557
Entity
Organization
Contact information
Practice address
3303 SUPERIOR AVE, SHEBOYGAN, WI 53081-1861
(920) 208-3557
(920) 208-3527
Mailing address
3303 SUPERIOR AVE, SHEBOYGAN, WI 53081-1861
(920) 208-3557
(920) 208-3527
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
40420500
—
WI
01
—
7725040
AETNA
WI
Enumeration date
11/01/2006
Last updated
08/22/2020
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