Healthcare Provider Details

I. General information

NPI: 1003105495
Provider Name (Legal Business Name): ELITE REHABILITATION INSTITUTE BRAIDWOOD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 E MAIN ST
BRAIDWOOD IL
60408-1912
US

IV. Provider business mailing address

180 E MAIN ST
BRAIDWOOD IL
60408-1912
US

V. Phone/Fax

Practice location:
  • Phone: 815-458-2225
  • Fax: 815-458-9825
Mailing address:
  • Phone: 815-458-2225
  • Fax: 815-458-9825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038009041
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070013955
License Number StateIL

VIII. Authorized Official

Name: DR. ANTHONY M PIRIE
Title or Position: OWNER
Credential: D.C.
Phone: 815-458-2225