Healthcare Provider Details

I. General information

NPI: 1366728560
Provider Name (Legal Business Name): IN-HOME PHYSICAL THERAPY AND WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2011
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 MILLBROOK CT
ALGONQUIN IL
60102-2542
US

IV. Provider business mailing address

7 MILLBROOK CT
ALGONQUIN IL
60102-2542
US

V. Phone/Fax

Practice location:
  • Phone: 217-653-6814
  • Fax: 877-482-0929
Mailing address:
  • Phone: 217-653-6814
  • Fax: 877-482-0929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL GAMBOA RIVERA
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 12176536814