Provider Demographics
NPI:1124105028
Name:GREAT LAKES PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:GREAT LAKES PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:920-208-3557
Mailing Address - Street 1:3303 SUPERIOR AVE
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53081-1861
Mailing Address - Country:US
Mailing Address - Phone:920-208-3557
Mailing Address - Fax:920-208-3527
Practice Address - Street 1:3303 SUPERIOR AVE
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1861
Practice Address - Country:US
Practice Address - Phone:920-208-3557
Practice Address - Fax:920-208-3527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40420500Medicaid
WI7725040OtherAETNA
WI7725040OtherAETNA
WI=========011OtherBLUE CROSS/BLUE SHIELD
WI=========022OtherBLUE CROSS/BLUE SHIELD