Healthcare Provider Details

I. General information

NPI: 1073226510
Provider Name (Legal Business Name): DAKOTA JOHN GREENWALT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2022
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2869 N LINCOLN AVE
CHICAGO IL
60657-4201
US

IV. Provider business mailing address

1621 N HONORE ST APT 3R
CHICAGO IL
60622-1303
US

V. Phone/Fax

Practice location:
  • Phone: 773-665-9950
  • Fax:
Mailing address:
  • Phone: 952-484-3644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070027339
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: