Healthcare Provider Details

I. General information

NPI: 1427712389
Provider Name (Legal Business Name): PHYSICAL WELLNESS LAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2021
Last Update Date: 11/14/2021
Certification Date: 11/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W BELMONT AVE
CHICAGO IL
60657-3200
US

IV. Provider business mailing address

1208 E LAKE AVE
GLENVIEW IL
60025-2265
US

V. Phone/Fax

Practice location:
  • Phone: 224-765-1598
  • Fax:
Mailing address:
  • Phone: 312-925-5325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: KATE NUGENT SHEAN
Title or Position: OWNER
Credential: PT
Phone: 312-925-5325