Healthcare Provider Details

I. General information

NPI: 1689807505
Provider Name (Legal Business Name): CHRISTINE PONG PT, DPT, OCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2009
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1397 MAIN ST
CRETE IL
60417-2951
US

IV. Provider business mailing address

1397 MAIN ST STE A
CRETE IL
60417-2951
US

V. Phone/Fax

Practice location:
  • Phone: 708-367-8050
  • Fax:
Mailing address:
  • Phone: 708-367-8050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070017344
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: