Healthcare Provider Details

I. General information

NPI: 1659482495
Provider Name (Legal Business Name): GENER TIGLAO DIZON PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5820 W IRVING PARK RD
CHICAGO IL
60634
US

IV. Provider business mailing address

2201 N NATCHEZ AVE
CHICAGO IL
60707
US

V. Phone/Fax

Practice location:
  • Phone: 773-685-8482
  • Fax: 773-685-8479
Mailing address:
  • Phone: 773-637-4186
  • Fax: 773-637-4186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: