Basic Information
| Provider Information | |||||||||
| NPI: | 1699063222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALAICHAMY | ||||||||
| FirstName: | TARA | ||||||||
| MiddleName: | THANANETAPON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.P.T. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THANANETAPON | ||||||||
| OtherFirstName: | TARA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.P.T. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2610 SHERIDAN ROAD | ||||||||
| Address2: | |||||||||
| City: | ZION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778847346 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2520 ELISHA AVENUE | ||||||||
| Address2: | |||||||||
| City: | ZION | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8477311605 | ||||||||
| FaxNumber: | 8478726176 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2011 | ||||||||
| LastUpdateDate: | 03/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | P12259 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.