MEDICARE: SOVEREIGN REHABILITATION OF ILLINOIS 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	261QP2000X	Physical Therapy Clinic/Center	070007656	IL

General Provider Information

NPI Number	:	1063739555
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOVEREIGN REHABILITATION OF ILLINOIS LLC

Provider Business Mailing Address
First Line	:	2835 N SHEFFIELD AVE
Second Line	:	SUITE 401
City	:	CHICAGO
State	:	IL
Zip	:	60657-5081
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2335 W 95TH ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60643-1003
Country	:	US
Telephone Number	:	773-755-7566
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	JOAN LAWRENCE
Credential	:
Telephone Number	:	773-755-7566

Provider Enumeration Date	:	04/23/2010
Last Update Date	:	04/23/2010

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