Healthcare Provider Details

I. General information

NPI: 1902800477
Provider Name (Legal Business Name): MOHINI M PANDYA P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2005
Last Update Date: 09/14/2012
Certification Date:
Deactivation Date: 03/16/2006
Reactivation Date: 03/31/2006

III. Provider practice location address

6800 MAIN ST STE 100
DOWNERS GROVE IL
60516-3498
US

IV. Provider business mailing address

6800 MAIN ST
DOWNERS GROVE IL
60516-3493
US

V. Phone/Fax

Practice location:
  • Phone: 630-437-5175
  • Fax: 630-437-5174
Mailing address:
  • Phone: 630-437-5175
  • Fax: 630-437-5174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070010481
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: