Healthcare Provider Details

I. General information

NPI: 1811128317
Provider Name (Legal Business Name): POLARIS PHYSICAL THERAPY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 REMINGTON BLVD SUITE E
BOLINGBROOK IL
60440-3656
US

IV. Provider business mailing address

215 REMINGTON BLVD SUITE E
BOLINGBROOK IL
60440-3656
US

V. Phone/Fax

Practice location:
  • Phone: 630-914-5943
  • Fax: 800-877-3496
Mailing address:
  • Phone: 630-914-5943
  • Fax: 800-877-3496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number212.000155
License Number StateIL

VIII. Authorized Official

Name: JOHN S DEGUZMAN
Title or Position: PRESIDENT
Credential: C. PED
Phone: 630-914-5943