1396119988 NPI number — SMITH PHYSICAL THERAPY AND RUNNING ACADEMY, LLC

Table of content: (NPI 1396119988)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396119988 NPI number — SMITH PHYSICAL THERAPY AND RUNNING ACADEMY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SMITH PHYSICAL THERAPY AND RUNNING ACADEMY, LLC
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:
6
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:
1396119988
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
215 EXCHANGE DR
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
CRYSTAL LAKE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60014-6206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-893-9075
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
215 EXCHANGE DR
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
CRYSTAL LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60014-6206
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-893-9075
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/19/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
DENISE
Authorized Official Middle Name:
FONTANA
Authorized Official Title or Position:
PHYSICAL THERAPIST; OWNER
Authorized Official Telephone Number:
815-893-9075

Provider Taxonomy Codes

  • Taxonomy code: 261QP2000X , with the licence number:  248001268 , 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)

  • Identifier: 1801989819 . This is a "UNKNOWN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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