Healthcare Provider Details

I. General information

NPI: 1255778023
Provider Name (Legal Business Name): SAMUEL THOMAS HUTTON PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2013
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 BUTTERFIELD TRL
KANKAKEE IL
60901-2959
US

IV. Provider business mailing address

2080 E OLD PINE BLUFF RD
MORRIS IL
60450-9670
US

V. Phone/Fax

Practice location:
  • Phone: 815-936-6500
  • Fax:
Mailing address:
  • Phone: 815-405-1958
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: