Healthcare Provider Details

I. General information

NPI: 1164766606
Provider Name (Legal Business Name): REVOLUTION PTWL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 N MICHIGAN AVE SUITE 973W
CHICAGO IL
60611
US

IV. Provider business mailing address

845 N MICHIGAN AVE SUITE 973W
CHICAGO IL
60611-2252
US

V. Phone/Fax

Practice location:
  • Phone: 312-878-8800
  • Fax: 312-448-9978
Mailing address:
  • Phone: 312-878-8800
  • Fax: 312-448-9978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. RANDOLPH FRIESER
Title or Position: PRESIDENT
Credential:
Phone: 312-878-8800