Provider Demographics
NPI:1043107428
Name:WISCONSIN ATHLETIC CLUB, LLC
Entity type:Organization
Organization Name:WISCONSIN ATHLETIC CLUB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MORGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-255-5700
Mailing Address - Street 1:10840 W ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-1135
Mailing Address - Country:US
Mailing Address - Phone:414-328-1300
Mailing Address - Fax:
Practice Address - Street 1:N91W15700 FALLS PKWY
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2301
Practice Address - Country:US
Practice Address - Phone:262-255-5700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-19
Last Update Date:2025-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care