Healthcare Provider Details

I. General information

NPI: 1679962989
Provider Name (Legal Business Name): KRZYSZTOF P WODZIEN PTA, PBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHRISTOPHER P WODZIEN

II. Dates (important events)

Enumeration Date: 01/12/2015
Last Update Date: 01/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 N MILWAUKEE AVE APT 1B
CHICAGO IL
60630-1200
US

IV. Provider business mailing address

5401 N MILWAUKEE AVE APT 1B
CHICAGO IL
60630-1200
US

V. Phone/Fax

Practice location:
  • Phone: 773-895-3589
  • Fax:
Mailing address:
  • Phone: 773-895-3589
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.006692
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number34950-25299956
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: