MEDICARE: YORKVILLE PHYSICAL THERAPY AND SPORTS MEDICINE CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist

General Provider Information

NPI Number	:	1053365403
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YORKVILLE PHYSICAL THERAPY AND SPORTS MEDICINE CENTER, LLC

Provider Business Mailing Address
First Line	:	1900 OGDEN AVE
Second Line	:	SUITE 205
City	:	AURORA
State	:	IL
Zip	:	60504-4273
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 OGDEN AVE
Second Line	:	SUITE 205
City	:	AURORA
State	:	IL
Zip	:	60504-4273
Country	:	US
Telephone Number	:	630-553-0349
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	CHARLES CLARK
Credential	:	P.T.
Telephone Number	:	630-978-6218

Provider Enumeration Date	:	05/20/2006
Last Update Date	:	12/17/2007

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