Healthcare Provider Details

I. General information

NPI: 1235633074
Provider Name (Legal Business Name): JUSTIN A RAGSDALE DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 08/31/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3644 W 111TH ST
CHICAGO IL
60655
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 773-779-8480
  • Fax:
Mailing address:
  • Phone: 630-575-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070023914
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: