1760650501 NPI number — TIMBER RIDGE PEDIATRIC THERAPY, LLC

Table of content: (NPI 1760650501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760650501 NPI number — TIMBER RIDGE PEDIATRIC THERAPY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TIMBER RIDGE PEDIATRIC THERAPY, 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:
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:
1760650501
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3716 DAVIS ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SKOKIE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60076-1745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-982-5822
Provider Business Mailing Address Fax Number:
847-982-5823

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8707 SKOKIE BLVD
Provider Second Line Business Practice Location Address:
SUITE 402
Provider Business Practice Location Address City Name:
SKOKIE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60077
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-877-5210
Provider Business Practice Location Address Fax Number:
847-510-0430
Provider Enumeration Date:
02/14/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GOLTZ
Authorized Official First Name:
LAURA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
847-804-0040

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 235Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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