Basic Information
| Provider Information | |||||||||
| NPI: | 1881367464 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANTAGE PHYSICAL THERAPY & SPORTS REHAB, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 150 | ||||||||
| Address2: | |||||||||
| City: | LIMA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458020150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192216717 | ||||||||
| FaxNumber: | 4192220507 | ||||||||
| Practice Location | |||||||||
| Address1: | S74W17045W JANESVILLE RD | ||||||||
| Address2: | |||||||||
| City: | MUSKEGO | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144224678 | ||||||||
| FaxNumber: | 4192220507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2021 | ||||||||
| LastUpdateDate: | 07/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | KENNEDY | ||||||||
| AuthorizedOfficialFirstName: | CALVIN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | GENERAL COUNSEL | ||||||||
| AuthorizedOfficialTelephone: | 7245444302 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
No ID Information.