Healthcare Provider Details

I. General information

NPI: 1043532047
Provider Name (Legal Business Name): JOHN LYNDON E LAO P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2010
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 MAPLE AVE.
HOMEWOOD IL
60430
US

IV. Provider business mailing address

940 MAPLE RD
HOMEWOOD IL
60430-2061
US

V. Phone/Fax

Practice location:
  • Phone: 708-799-0244
  • Fax:
Mailing address:
  • Phone: 708-799-0244
  • Fax: 708-799-1505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-006934
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: