Provider Demographics
NPI:1609756204
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:JESSICA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KIESER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-212-2000
Mailing Address - Street 1:411 E WISCONSIN AVE FL 6
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-4461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:411 E WISCONSIN AVE FL 6
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-4461
Practice Address - Country:US
Practice Address - Phone:414-212-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WISCONSIN ATHLETIC CLUB, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-09-04
Last Update Date:2025-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty