Provider Demographics
NPI:1205954369
Name:SPINE & ORTHOPEDIC PHYSICAL THERAPY
Entity type:Organization
Organization Name:SPINE & ORTHOPEDIC PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF PRACTICE AND P.T.
Authorized Official - Prefix:
Authorized Official - First Name:OLALEKAN
Authorized Official - Middle Name:LUKMAN
Authorized Official - Last Name:GANIYU
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:608-368-9783
Mailing Address - Street 1:2958 PRAIRIE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1825
Mailing Address - Country:US
Mailing Address - Phone:608-368-9783
Mailing Address - Fax:
Practice Address - Street 1:2958 PRAIRIE AVE STE B
Practice Address - Street 2:
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1825
Practice Address - Country:US
Practice Address - Phone:608-368-9783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5648-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI540545994009OtherBLUE CROSS NUMBER
WI40403900Medicaid
WI81052Medicare ID - Type Unspecified