MEDICARE: MS. OMEGA AMY T KAPUNO 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	225100000X	Physical Therapist	070009185	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	203	OTHER	IL	BLUE CROSS PROV ID
2	4117	OTHER	IL	HAMP PROV ID
3	7216	OTHER		PERSONALCARE PROV ID
4	113326	OTHER		HEALTHLINK PROV ID

General Provider Information

NPI Number	:	1720105612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. OMEGA AMY T KAPUNO PT

Provider Business Mailing Address
First Line	:	611 W PARK ST
Second Line	:
City	:	URBANA
State	:	IL
Zip	:	61801-2500
Country	:	US
Telephone Number	:	217-326-2911
Fax Number	:	217-344-8047

Provider Business Practice Location Address
First Line	:	1504 EAST GROVE
Second Line	:
City	:	RANTOUL
State	:	IL
Zip	:	61866-2736
Country	:	US
Telephone Number	:	217-893-7720
Fax Number	:	217-893-7803

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

Provider Enumeration Date	:	03/23/2007
Last Update Date	:	09/20/2019

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