Healthcare Provider Details

I. General information

NPI: 1942379110
Provider Name (Legal Business Name): ORTHO-SPORT, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 DES PLAINES AVE
FOREST PARK IL
60130-2035
US

IV. Provider business mailing address

800 DES PLAINES AVE
FOREST PARK IL
60130-2035
US

V. Phone/Fax

Practice location:
  • Phone: 708-366-2442
  • Fax: 708-366-0179
Mailing address:
  • Phone: 708-366-2442
  • Fax: 708-366-0179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MICHAEL EDWARD KEENUM
Title or Position: OWNER PRESIDENT
Credential: PT
Phone: 708-366-2442