Basic Information
| Provider Information | |||||||||
| NPI: | 1831641844 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPORTS PHYSICAL THERAPY & REHAB SPECIALIST SC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 OAKMONT LN # 600C | ||||||||
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| City: | WESTMONT | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605595548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305751980 | ||||||||
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| Practice Location | |||||||||
| Address1: | 25250 75TH ST | ||||||||
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| City: | SALEM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531688705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2628434200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2016 | ||||||||
| LastUpdateDate: | 04/10/2018 | ||||||||
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| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | GERI | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF BILLING OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 6305751940 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.