Healthcare Provider Details

I. General information

NPI: 1124630140
Provider Name (Legal Business Name): JOSEPH VIRGILIO B PABLO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 W HARRISON ST STE 107
CHICAGO IL
60612-4861
US

IV. Provider business mailing address

1611 W HARRISON ST STE 107
CHICAGO IL
60612-4861
US

V. Phone/Fax

Practice location:
  • Phone: 877-632-6637
  • Fax: 708-409-5179
Mailing address:
  • Phone: 877-632-6637
  • Fax: 708-409-5179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.025376
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: