1003435934 NPI number — THE TABOR THERAPY GROUP, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003435934 NPI number — THE TABOR THERAPY GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE TABOR THERAPY GROUP, 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:
1003435934
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/10/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5404 W ELM ST STE H
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCHENRY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60050-4007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-331-8768
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12151 REGENCY PKWY STE 12169
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTLEY
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60142-7644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-331-8768
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/10/2020

Additional Information

Authorized Official

Authorized Official Last Name:
TABOR
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
815-331-8768

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2B17-IPI-002 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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