Basic Information
| Provider Information | |||||||||
| NPI: | 1730109596 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEW LIFE PHYSICAL THERAPY AND REHABILITATION P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 379 | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604620379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7087742970 | ||||||||
| FaxNumber: | 7084601117 | ||||||||
| Practice Location | |||||||||
| Address1: | 25622 S GOVERNORS HWY | ||||||||
| Address2: | |||||||||
| City: | MONEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604498987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7082350144 | ||||||||
| FaxNumber: | 7082350145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 10/24/2007 | ||||||||
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| AuthorizedOfficialLastName: | KOOYENGA | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7087742970 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 09932272 | 01 | IL | BCBS IL | OTHER |