Healthcare Provider Details

I. General information

NPI: 1194237677
Provider Name (Legal Business Name): ADAM JOSEPH MOODY PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2017
Last Update Date: 10/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 DURELL DR
KANKAKEE IL
60901-6001
US

IV. Provider business mailing address

7 DURELL DR
KANKAKEE IL
60901-6001
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number160006509
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: