Healthcare Provider Details

I. General information

NPI: 1922567809
Provider Name (Legal Business Name): MOVEMENT SYNERGY PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2019
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 N RACINE AVE STE 1000B
CHICAGO IL
60614-7011
US

IV. Provider business mailing address

1746 W HURON ST APT 3E
CHICAGO IL
60622-5631
US

V. Phone/Fax

Practice location:
  • Phone: 630-664-6298
  • Fax: 312-253-1408
Mailing address:
  • Phone: 630-664-6298
  • Fax: 312-253-1408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHARLES JOHN RANDA
Title or Position: OWNER
Credential: PT, DPT, OCS, CSCS
Phone: 630-664-6298