Healthcare Provider Details

I. General information

NPI: 1801250378
Provider Name (Legal Business Name): ATHLETICO LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 08/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3467 S. DR MARTIN L KING JR DR
CHICAGO IL
60616
US

IV. Provider business mailing address

625 ENTERPRISE DR.
OAK BROOK IL
60523-8813
US

V. Phone/Fax

Practice location:
  • Phone: 312-225-9070
  • Fax: 312-225-9072
Mailing address:
  • Phone: 630-575-6250
  • Fax: 630-575-7450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number060005437
License Number StateIL

VIII. Authorized Official

Name: GERI COOK
Title or Position: DIRECTOR OF CLINICAL SERVICES
Credential:
Phone: 630-575-1940