Basic Information
| Provider Information | |||||||||
| NPI: | 1740548916 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INCREMEDICAL, LLC | ||||||||
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| OtherOrganizationName: | LEAP REHABILITATION & SPORTS MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8259 WICKER AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT JOHN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463738878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193656560 | ||||||||
| FaxNumber: | 2193656561 | ||||||||
| Practice Location | |||||||||
| Address1: | 4195 W BRADLEY RD | ||||||||
| Address2: | |||||||||
| City: | BROWN DEER | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532091700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4145860046 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2012 | ||||||||
| LastUpdateDate: | 04/25/2012 | ||||||||
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| AuthorizedOfficialLastName: | TOWASNICKI | ||||||||
| AuthorizedOfficialFirstName: | LAUREN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | BILLING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2193656560 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.