Basic Information
| Provider Information | |||||||||
| NPI: | 1710097407 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | YOUNG | ||||||||
| FirstName: | NICHOLAS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2525 KANEVILLE RD | ||||||||
| Address2: | |||||||||
| City: | GENEVA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601342575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305841411 | ||||||||
| FaxNumber: | 6305132630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/07/2015 | ||||||||
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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 | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 070012494 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | CF2064 | 01 | IL | RAILROAD GROUP | OTHER | 070-012494 | 01 | IL | LICENSE # | OTHER | 753210 | 01 | IL | MEDICARE GROUP | OTHER | K40726 | 01 | IL | MEDICARE | OTHER |