Healthcare Provider Details

I. General information

NPI: 1275931156
Provider Name (Legal Business Name): MIDWEST PCW PT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

849 S ROUTE 51
FORSYTH IL
62535-8807
US

IV. Provider business mailing address

15 APEX DR
HIGHLAND IL
62249-1282
US

V. Phone/Fax

Practice location:
  • Phone: 217-864-2085
  • Fax: 217-864-2324
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: REBECCA ANDERSON
Title or Position: MANAGING PARTNER/OWNER
Credential:
Phone: 217-000-0000