Provider Demographics
NPI:1174360176
Name:WILD PHYSICAL THERAPY AND WELLNESS LLC
Entity type:Organization
Organization Name:WILD PHYSICAL THERAPY AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MOLLYE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEAS-MEDREK
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:812-662-5033
Mailing Address - Street 1:555 N MAIN ST # 1439
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-5722
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:545 PAWTUCKET AVE # LL04A
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-6046
Practice Address - Country:US
Practice Address - Phone:812-662-5033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty