Healthcare Provider Details

I. General information

NPI: 1659942183
Provider Name (Legal Business Name): -
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2021
Last Update Date: 07/06/2021
Certification Date: 07/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2972 SHAMROCK CIR
ELGIN IL
60124-4354
US

IV. Provider business mailing address

2972 SHAMROCK CIR
ELGIN IL
60124-4354
US

V. Phone/Fax

Practice location:
  • Phone: 224-465-1479
  • Fax:
Mailing address:
  • Phone: 224-465-1479
  • 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: RICHARD W EADEN
Title or Position: OWNER
Credential: MPT
Phone: 224-465-1479