Basic Information
| Provider Information | |||||||||
| NPI: | 1114109790 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAN | ||||||||
| FirstName: | REGINA | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16101 WEBER RD | ||||||||
| Address2: | |||||||||
| City: | CRESTHILL | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604038812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8153061100 | ||||||||
| FaxNumber: | 8153061105 | ||||||||
| Practice Location | |||||||||
| Address1: | 2320-2324 WEST JEFFERSON STREET | ||||||||
| Address2: | |||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60435 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157413758 | ||||||||
| FaxNumber: | 8157413974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2007 | ||||||||
| LastUpdateDate: | 11/05/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070015693 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.