Healthcare Provider Details

I. General information

NPI: 1245797075
Provider Name (Legal Business Name): ATHLETICO, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 W PETERSON AVE
CHICAGO IL
60659-3818
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 773-596-5484
  • Fax: 773-862-8578
Mailing address:
  • Phone: 630-575-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUANA GRANADOS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 630-575-1980