Provider Demographics
NPI:1053512095
Name:BACK IN ACTION REHABILITATION S.C.
Entity type:Organization
Organization Name:BACK IN ACTION REHABILITATION S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:WUNSCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:920-922-7776
Mailing Address - Street 1:103 S PIONEER RD # 100
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3871
Mailing Address - Country:US
Mailing Address - Phone:920-922-7776
Mailing Address - Fax:
Practice Address - Street 1:1057 FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:KEWASKUM
Practice Address - State:WI
Practice Address - Zip Code:53040-9495
Practice Address - Country:US
Practice Address - Phone:262-626-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BACK IN ACTION REHABILITATION SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-29
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000081830Medicare ID - Type Unspecified