Healthcare Provider Details

I. General information

NPI: 1023064144
Provider Name (Legal Business Name): EASTERN IOWA THERAPEUTICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 10/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2406 MOMENTUM PL
CHICAGO IL
60689-0001
US

IV. Provider business mailing address

205 W WACKER DR SUITE 1020
CHICAGO IL
60606-1216
US

V. Phone/Fax

Practice location:
  • Phone: 815-577-2480
  • Fax: 815-577-7535
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateIA
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number02757
License Number StateIA

VIII. Authorized Official

Name: RANDOLPH P FRIESER
Title or Position: PRESIDENT SECRETARY
Credential: PT
Phone: 312-640-0329