MEDICARE: MA. LOURDES L IPAPO PT

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	070015513	IL

General Provider Information

NPI Number	:	1255689220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MA. LOURDES L IPAPO PT

Provider Business Mailing Address
First Line	:	5461 N EAST RIVER RD
Second Line	:	APT 900
City	:	CHICAGO
State	:	IL
Zip	:	60656-1128
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5421 N EAST RIVER RD
Second Line	:	APT 404
City	:	CHICAGO
State	:	IL
Zip	:	60656-1129
Country	:	US
Telephone Number	:	773-895-7599
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2012
Last Update Date	:	08/11/2013

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