Healthcare Provider Details

I. General information

NPI: 1225790777
Provider Name (Legal Business Name): NATHAN JAMES BOWERS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 10/12/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

485 BUTTERFIELD TRAIL
KANKAKEE IL
60901
US

IV. Provider business mailing address

798 N 10TH AVE
KANKAKEE IL
60901-2222
US

V. Phone/Fax

Practice location:
  • Phone: 815-216-1973
  • Fax:
Mailing address:
  • Phone: 815-216-1973
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.009331
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: