Healthcare Provider Details

I. General information

NPI: 1629711908
Provider Name (Legal Business Name): DAVID JOHN GUZMAN NULUD PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 W PETERSON AVE
CHICAGO IL
60659-4017
US

IV. Provider business mailing address

2655 W PETERSON AVE
CHICAGO IL
60659-4017
US

V. Phone/Fax

Practice location:
  • Phone: 773-942-6528
  • Fax: 773-293-6550
Mailing address:
  • Phone: 773-942-6528
  • Fax: 773-293-6550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160009445
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: