Provider Demographics
NPI:1447888136
Name:FRESH START PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:FRESH START PHYSICAL THERAPY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARISE
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-236-0176
Mailing Address - Street 1:10412 N BAEHR RD
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-4472
Mailing Address - Country:US
Mailing Address - Phone:262-236-0176
Mailing Address - Fax:262-236-0178
Practice Address - Street 1:10412 N BAEHR RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-4472
Practice Address - Country:US
Practice Address - Phone:262-236-0176
Practice Address - Fax:262-236-0178
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-30
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty