Healthcare Provider Details

I. General information

NPI: 1972049385
Provider Name (Legal Business Name): PHYSICAL THERAPY AND COSMETOLOGY INTEGRATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2017
Last Update Date: 01/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5515 W NORTH AVE
CHICAGO IL
60639-4207
US

IV. Provider business mailing address

5515 W NORTH AVE
CHICAGO IL
60639-4207
US

V. Phone/Fax

Practice location:
  • Phone: 312-296-1404
  • Fax:
Mailing address:
  • Phone: 312-296-1404
  • 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: MR. APOLINARIO OCCENA DELA CRUZ JR.
Title or Position: PRESIDENT
Credential:
Phone: 312-296-1404