Provider Demographics
NPI:1104299940
Name:SPORTS PHYSICAL THERAPISTS, LLC
Entity type:Organization
Organization Name:SPORTS PHYSICAL THERAPISTS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT/COO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:TENUTA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:262-925-5003
Mailing Address - Street 1:3921 30TH AVE STE C
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1957
Mailing Address - Country:US
Mailing Address - Phone:262-925-5004
Mailing Address - Fax:262-925-5001
Practice Address - Street 1:10222 74TH ST
Practice Address - Street 2:SUITE 211
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-6810
Practice Address - Country:US
Practice Address - Phone:262-925-5020
Practice Address - Fax:262-925-5021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK100270270Medicare PIN