Provider Demographics
NPI:1679548846
Name:ACTRA REHABILITATION ASSOCIATES INC
Entity type:Organization
Organization Name:ACTRA REHABILITATION ASSOCIATES INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TARVIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-972-1100
Mailing Address - Street 1:525 E DIVISION ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-3747
Mailing Address - Country:US
Mailing Address - Phone:920-923-6676
Mailing Address - Fax:920-923-9020
Practice Address - Street 1:525 E DIVISION ST
Practice Address - Street 2:SUITE 104
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-3747
Practice Address - Country:US
Practice Address - Phone:920-923-6676
Practice Address - Fax:920-923-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-21
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41790300Medicaid
WI0237460002Medicare NSC