Basic Information
| Provider Information | |||||||||
| NPI: | 1073072609 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRISTALES | ||||||||
| FirstName: | JAYCEE | ||||||||
| MiddleName: | CABALATUNGAN | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1737 S COUNTRY CLUB RD APT 107 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625214486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053288673 | ||||||||
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| Practice Location | |||||||||
| Address1: | 136 S DIPPER LN | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625221841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2174287767 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2019 | ||||||||
| LastUpdateDate: | 03/13/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070023533 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.