Basic Information
| Provider Information | |||||||||
| NPI: | 1811621840 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ATHLETICO LTD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2122 YORK RD STE 300 | ||||||||
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| City: | OAK BROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605231925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305756250 | ||||||||
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| Practice Location | |||||||||
| Address1: | 16605 15 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480352206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867650650 | ||||||||
| FaxNumber: | 5863009650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2022 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
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| AuthorizedOfficialLastName: | GRANADOS | ||||||||
| AuthorizedOfficialFirstName: | JUANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 6305751980 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.