Healthcare Provider Details

I. General information

NPI: 1528725900
Provider Name (Legal Business Name): RESTORE NEUROREHAB PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2021
Last Update Date: 11/20/2021
Certification Date: 11/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 S GROVE AVE
BARRINGTON IL
60010-5211
US

IV. Provider business mailing address

306 S WAVERLY PL
MT PROSPECT IL
60056-2939
US

V. Phone/Fax

Practice location:
  • Phone: 847-800-6162
  • Fax:
Mailing address:
  • Phone: 847-345-3375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK ANDREW FASICK
Title or Position: MANAGER
Credential: PT, MS, NCS
Phone: 847-345-3375