Basic Information
| Provider Information | |||||||||
| NPI: | 1598763864 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DYNACARE PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 S HI LUSI AVE | ||||||||
| Address2: | |||||||||
| City: | MT PROSPECT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600563025 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1455 E GOLF RD | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600161250 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473907666 | ||||||||
| FaxNumber: | 8473909345 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 02/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | PETRICCA | ||||||||
| AuthorizedOfficialFirstName: | DINA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8473907666 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | PT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | IL | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 166=33438 | 01 | IL | BCBS | OTHER |