Healthcare Provider Details

I. General information

NPI: 1437131497
Provider Name (Legal Business Name): SPORTHO PHYSICAL AND AQUATIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 04/07/2020
Certification Date: 04/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6921 W ARCHER AVE
CHICAGO IL
60638-2319
US

IV. Provider business mailing address

6921 W ARCHER AVE
CHICAGO IL
60638-2319
US

V. Phone/Fax

Practice location:
  • Phone: 773-586-2768
  • Fax: 773-586-2780
Mailing address:
  • Phone: 773-586-2768
  • Fax: 773-586-2780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM A CAPRARO III
Title or Position: BUSINESS MANAGER
Credential:
Phone: 773-586-2768