Healthcare Provider Details

I. General information

NPI: 1487851283
Provider Name (Legal Business Name): TIMOTHY RAY PRICE CPO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N LARKIN AVE SUITE 207
JOLIET IL
60435-3438
US

IV. Provider business mailing address

7633 CHURCH ST
MORTON GROVE IL
60053-1618
US

V. Phone/Fax

Practice location:
  • Phone: 815-207-4200
  • Fax: 815-207-4200
Mailing address:
  • Phone: 847-470-1287
  • Fax: 847-470-1287

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number211-000025
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number213-000028
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number211-000025
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: