Healthcare Provider Details

I. General information

NPI: 1881963163
Provider Name (Legal Business Name): INNOVATIVE SPORTS MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2011
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 W FABYAN PKWY
BATAVIA IL
60510-1267
US

IV. Provider business mailing address

501 W FABYAN PKWY
BATAVIA IL
60510-1267
US

V. Phone/Fax

Practice location:
  • Phone: 630-524-2445
  • Fax:
Mailing address:
  • Phone: 630-524-2445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038011756
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070019008
License Number StateIL

VIII. Authorized Official

Name: ERIC HESTRUP
Title or Position: MEMBER
Credential: D.C.
Phone: 630-788-7990