Provider Demographics
NPI:1154599082
Name:NEW LIFE PHYSICAL THERAPY & SPORTS MEDICINE BARABOO, LLC
Entity type:Organization
Organization Name:NEW LIFE PHYSICAL THERAPY & SPORTS MEDICINE BARABOO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CUMMINGS
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:608-356-2334
Mailing Address - Street 1:840 US HIGHWAY 12
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-9277
Mailing Address - Country:US
Mailing Address - Phone:608-356-2334
Mailing Address - Fax:608-356-2636
Practice Address - Street 1:840 US HIGHWAY 12
Practice Address - Street 2:SUITE 3
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-9277
Practice Address - Country:US
Practice Address - Phone:608-356-2334
Practice Address - Fax:608-356-2636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIAPPLIED FOR225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIAPPLIED FOR ALLOtherALL APPLIED FOR