MEDICARE: MOONWATER HEALING CENTER

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	070011216	IL

General Provider Information

NPI Number	:	1831334333
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOONWATER HEALING CENTER

Provider Business Mailing Address
First Line	:	6960 N SHERIDAN RD
Second Line	:	1A
City	:	CHICAGO
State	:	IL
Zip	:	60626-3888
Country	:	US
Telephone Number	:	773-793-3483
Fax Number	:	773-856-6440

Provider Business Practice Location Address
First Line	:	6960 N SHERIDAN RD
Second Line	:	1A
City	:	CHICAGO
State	:	IL
Zip	:	60626-3888
Country	:	US
Telephone Number	:	773-793-3483
Fax Number	:	773-856-6440

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	MR. TIMOTHY PATRICK ZEPELAK
Credential	:	P.T.
Telephone Number	:	773-793-3483

Provider Enumeration Date	:	12/11/2008
Last Update Date	:	12/11/2008

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