Healthcare Provider Details

I. General information

NPI: 1720419732
Provider Name (Legal Business Name): THE EXCELLENCE GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2013
Last Update Date: 12/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 E 46TH ST UNIT 202
CHICAGO IL
60653-4435
US

IV. Provider business mailing address

1102 E 46TH ST UNIT 202
CHICAGO IL
60653-4435
US

V. Phone/Fax

Practice location:
  • Phone: 708-359-9899
  • Fax:
Mailing address:
  • Phone: 708-359-9899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number070012853
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number070012853
License Number StateIL

VIII. Authorized Official

Name: TEKELA R SCOTT
Title or Position: OWNER
Credential: MPT
Phone: 708-359-9899