Healthcare Provider Details

I. General information

NPI: 1306215835
Provider Name (Legal Business Name): GRANT PANZELLA PT, DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2015
Last Update Date: 11/01/2021
Certification Date: 11/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11917 LERWICK RD
CALEDONIA IL
61011-9781
US

IV. Provider business mailing address

11917 LERWICK RD
CALEDONIA IL
61011-9781
US

V. Phone/Fax

Practice location:
  • Phone: 815-914-6650
  • Fax:
Mailing address:
  • Phone: 815-914-6650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.026061
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: