1811181191 NPI number — LIVING WELL PHYSICAL THERAPY INC

Table of content: (NPI 1811181191)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811181191 NPI number — LIVING WELL PHYSICAL THERAPY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING WELL PHYSICAL THERAPY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811181191
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/18/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1026 WRENS GATE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUNDELEIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60060-1268
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-651-4419
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
450 N SEYMOUR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUNDELEIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60060-1835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-949-4262
Provider Business Practice Location Address Fax Number:
847-949-8526
Provider Enumeration Date:
08/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ZAGULA
Authorized Official First Name:
BRENDA
Authorized Official Middle Name:
KAY
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
847-651-4419

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  070.007536 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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