Healthcare Provider Details

I. General information

NPI: 1083769475
Provider Name (Legal Business Name): PHYSICAL THERAPISTS CLINIC, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 05/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1440 W WALNUT ST SUITE2
JACKSONVILLE IL
62650-1143
US

IV. Provider business mailing address

1440 W WALNUT ST SUITE2
JACKSONVILLE IL
62650-1143
US

V. Phone/Fax

Practice location:
  • Phone: 217-245-1325
  • Fax: 217-243-6903
Mailing address:
  • Phone: 217-245-1325
  • Fax: 217-243-6903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number203000094
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. CHERYL DIANE BARBER
Title or Position: INSURANCE MANAGER
Credential:
Phone: 217-245-1325