Healthcare Provider Details

I. General information

NPI: 1053365403
Provider Name (Legal Business Name): YORKVILLE PHYSICAL THERAPY AND SPORTS MEDICINE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 OGDEN AVE SUITE 205
AURORA IL
60504-4273
US

IV. Provider business mailing address

1900 OGDEN AVE SUITE 205
AURORA IL
60504-4273
US

V. Phone/Fax

Practice location:
  • Phone: 630-553-0349
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHARLES CLARK
Title or Position: OWNER
Credential: P.T.
Phone: 630-978-6218