MEDICARE: MACK PHYSICAL THERAPY 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	070.012671	IL

General Provider Information

NPI Number	:	1720479041
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MACK PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	1946 W NEWPORT AVE
Second Line	:	APT 3E
City	:	CHICAGO
State	:	IL
Zip	:	60657-1123
Country	:	US
Telephone Number	:	312-527-2701
Fax Number	:	312-527-9202

Provider Business Practice Location Address
First Line	:	227 E ONTARIO ST
Second Line	:	STE 201
City	:	CHICAGO
State	:	IL
Zip	:	60611-3385
Country	:	US
Telephone Number	:	312-527-2701
Fax Number	:	312-527-9202

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CORI MACK
Credential	:	MSPT
Telephone Number	:	312-527-2701

Provider Enumeration Date	:	02/09/2015
Last Update Date	:	02/09/2015

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