Healthcare Provider Details

I. General information

NPI: 1255956751
Provider Name (Legal Business Name): EXPERIENCE PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2020
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 ABBOTT CT
BUFFALO GROVE IL
60089-2378
US

IV. Provider business mailing address

8928 MARMORA AVE
MORTON GROVE IL
60053-2447
US

V. Phone/Fax

Practice location:
  • Phone: 847-917-1476
  • Fax:
Mailing address:
  • Phone: 847-917-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: DANIEL LE
Title or Position: PHYSICAL THERAPIST
Credential: DPT
Phone: 847-917-1476