Basic Information
| Provider Information | |||||||||
| NPI: | 1962679290 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPECKMAN THERAPEUTICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 88 SCHOOLHOUSE RD | ||||||||
| Address2: | |||||||||
| City: | YORKVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605609046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305536888 | ||||||||
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| Practice Location | |||||||||
| Address1: | 88 SCHOOLHOUSE RD | ||||||||
| Address2: | |||||||||
| City: | YORKVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605609046 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305536888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2008 | ||||||||
| LastUpdateDate: | 01/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | SPECKMAN | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6305536888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | P.T. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | 070-007763 | IL | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 4732110 | 01 | IL | BLUE CROSS BLUE SHIELD ILLINOIS | OTHER |