1770860124 NPI number — HEALTHY CONNECTION PHYSICAL MEDICINE INC

Table of content: (NPI 1770860124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770860124 NPI number — HEALTHY CONNECTION PHYSICAL MEDICINE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHY CONNECTION PHYSICAL MEDICINE 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:
1770860124
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16626 W 159TH ST
Provider Second Line Business Mailing Address:
SUITE700
Provider Business Mailing Address City Name:
LOCKPORT
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60441-8018
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-834-9075
Provider Business Mailing Address Fax Number:
815-834-9077

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16626 W 159TH ST
Provider Second Line Business Practice Location Address:
SUITE700
Provider Business Practice Location Address City Name:
LOCKPORT
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60441-8018
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-834-9075
Provider Business Practice Location Address Fax Number:
815-834-9077
Provider Enumeration Date:
11/14/2011

Additional Information

Authorized Official

Authorized Official Last Name:
PUODZIUNAS
Authorized Official First Name:
VICTOR
Authorized Official Middle Name:
Authorized Official Title or Position:
TREASURER
Authorized Official Telephone Number:
815-834-9075

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  036126664 , 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)





Copyright © 2007-2025 www.npivalidator.com