Healthcare Provider Details

I. General information

NPI: 1104885136
Provider Name (Legal Business Name): SELECT PHYSICAL THERAPY OF ILLINOIS LIMITED PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 09/01/2010
Certification Date:
Deactivation Date: 11/20/2007
Reactivation Date: 01/04/2008

III. Provider practice location address

820 E TERRA COTTA AVE STE 102
CRYSTAL LAKE IL
60014
US

IV. Provider business mailing address

4714 GETTYSBURG RD
MECHANICSBURG PA
17055-4325
US

V. Phone/Fax

Practice location:
  • Phone: 815-455-3262
  • Fax: 815-455-2729
Mailing address:
  • Phone: 717-972-1100
  • Fax: 717-975-9781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL E TARVIN
Title or Position: VICE PRESIDENT
Credential:
Phone: 717-972-1100