Basic Information
| Provider Information | |||||||||
| NPI: | 1376780205 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FULLERTON REHABILITATION CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6445 N CENTRAL AVE | ||||||||
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| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606462901 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4849 W FULLERTON AVE | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606392503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7732372900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2009 | ||||||||
| LastUpdateDate: | 01/14/2009 | ||||||||
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| AuthorizedOfficialLastName: | NAULTY | ||||||||
| AuthorizedOfficialFirstName: | MARGARET | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PT | ||||||||
| AuthorizedOfficialTelephone: | 7735940225 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070.005171 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.