Basic Information
| Provider Information | |||||||||
| NPI: | 1851830236 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOMAN | ||||||||
| FirstName: | SAMANTHA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRUSE | ||||||||
| OtherFirstName: | SAMANTHA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962223 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 509 HAMACHER ST | ||||||||
| Address2: | SUITE101 | ||||||||
| City: | WATERLOO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622981592 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6189395555 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2017 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070022815 | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.