Basic Information
| Provider Information | |||||||||
| NPI: | 1295139236 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CRESPO | ||||||||
| FirstName: | JOSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 ENTERPRISE DR | ||||||||
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| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605238813 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 315 N MILWAUKEE ST | ||||||||
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| City: | WATERFORD | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531854432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2625142700 | ||||||||
| FaxNumber: | 2625143003 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2014 | ||||||||
| LastUpdateDate: | 03/21/2016 | ||||||||
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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 | 12810-24 | WI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.