Healthcare Provider Details

I. General information

NPI: 1609010545
Provider Name (Legal Business Name): A BIG BLAST PROJECT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2009
Last Update Date: 05/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 LINNEMAN ST
GLENVIEW IL
60025-4168
US

IV. Provider business mailing address

2210 LINNEMAN ST
GLENVIEW IL
60025-4168
US

V. Phone/Fax

Practice location:
  • Phone: 847-650-8161
  • Fax:
Mailing address:
  • Phone: 847-650-8161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number StateIL

VIII. Authorized Official

Name: RHONDA PENZELL
Title or Position: PRESIDENT
Credential:
Phone: 847-650-8161