Healthcare Provider Details

I. General information

NPI: 1992638720
Provider Name (Legal Business Name): KEVYN RODRIGUEZ PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6526 S PULASKI RD
CHICAGO IL
60629-5136
US

IV. Provider business mailing address

1306 S 49TH CT
CICERO IL
60804-1425
US

V. Phone/Fax

Practice location:
  • Phone: 773-585-9460
  • Fax:
Mailing address:
  • Phone: 312-678-5069
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.010638
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: