Healthcare Provider Details

I. General information

NPI: 1376930982
Provider Name (Legal Business Name): PHYSICAL THERAPY & SPORTS INJURY REHABILITATION LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 09/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1816 170TH ST
HAZEL CREST IL
60429-1451
US

IV. Provider business mailing address

1816 170TH ST
HAZEL CREST IL
60429-1451
US

V. Phone/Fax

Practice location:
  • Phone: 708-335-4081
  • Fax:
Mailing address:
  • Phone: 708-335-4081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number227.002610
License Number StateIL

VIII. Authorized Official

Name: RONALD F AGRIGENTO
Title or Position: PHYSICAL THERAPIST
Credential: DPT,ATC
Phone: 708-335-4081