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NPI Code Detail

MEDICARE: SMITH PHYSICAL THERAPY AND RUNNING ACADEMY, LLC

MEDICARE: SMITH PHYSICAL THERAPY AND RUNNING ACADEMY, 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
1261QP2000XPhysical Therapy Clinic/Center248001268IL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11801989819OTHERILUNKNOWN

General Provider Information

NPI Number : 1396119988
Entity Type Code : Organization
Provider Name (Legal Business Name) : SMITH PHYSICAL THERAPY AND RUNNING ACADEMY, LLC
Provider Business Mailing Address
First Line : 215 EXCHANGE DR
Second Line : SUITE E
City : CRYSTAL LAKE
State : IL
Zip : 60014-6206
Country : US
Telephone Number : 815-893-9075
Fax Number :
Provider Business Practice Location Address
First Line : 215 EXCHANGE DR
Second Line : SUITE E
City : CRYSTAL LAKE
State : IL
Zip : 60014-6206
Country : US
Telephone Number : 815-893-9075
Fax Number :
Authorized Official
Title or Position : PHYSICAL THERAPIST; OWNER
Name : DENISE FONTANA SMITH
Credential : PT
Telephone Number : 815-893-9075
Provider Enumeration Date : 11/19/2015
Last Update Date : 04/25/2017

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