Healthcare Provider Details

I. General information

NPI: 1790699056
Provider Name (Legal Business Name): PETER CHIONG PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2026
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 ENVEE DR
BOLINGBROOK IL
60490-6585
US

IV. Provider business mailing address

205 W GRAND AVE STE 101
BENSENVILLE IL
60106-3397
US

V. Phone/Fax

Practice location:
  • Phone: 630-209-0985
  • Fax:
Mailing address:
  • Phone: 866-573-2556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.003383
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: