Provider Demographics
NPI:1548705544
Name:SPORTS PHYSICAL THERAPISTS OF FOX LAKE LLC
Entity type:Organization
Organization Name:SPORTS PHYSICAL THERAPISTS OF FOX LAKE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:
Authorized Official - First Name:CARMELO
Authorized Official - Middle Name:D
Authorized Official - Last Name:TENUTA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:262-925-5000
Mailing Address - Street 1:3921 30TH AVE STE C
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-1957
Mailing Address - Country:US
Mailing Address - Phone:262-925-5004
Mailing Address - Fax:262-925-5001
Practice Address - Street 1:145 SAYTON RD
Practice Address - Street 2:STE F
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1739
Practice Address - Country:US
Practice Address - Phone:847-629-5536
Practice Address - Fax:847-629-5163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-29
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty