Basic Information
| Provider Information | |||||||||
| NPI: | 1023537610 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TEAM REHABILITATION WI01, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33900 HARPER AVE STE 104 | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480354258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5863502644 | ||||||||
| FaxNumber: | 5864169103 | ||||||||
| Practice Location | |||||||||
| Address1: | N81W15014 APPLETON AVE | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530513839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2627147040 | ||||||||
| FaxNumber: | 2627147041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2017 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| AuthorizedOfficialLastName: | WEBER | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | NICHOLAS | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5863502644 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TEAM REHABILITATION SERVICES, LLC | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.