Healthcare Provider Details

I. General information

NPI: 1124527650
Provider Name (Legal Business Name): JOREK BORDAS COMBENIDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2018
Last Update Date: 02/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4340 N KEYSTONE AVE
CHICAGO IL
60641-2121
US

IV. Provider business mailing address

4265 N MOBILE AVE
CHICAGO IL
60634-1585
US

V. Phone/Fax

Practice location:
  • Phone: 773-545-8700
  • Fax:
Mailing address:
  • Phone: 224-703-4949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070022771
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: