Healthcare Provider Details

I. General information

NPI: 1871929703
Provider Name (Legal Business Name): JOHN ANDREW LEVANDER III P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2013
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22320 CLASSIC CT
LAKE BARRINGTON IL
60010-5903
US

IV. Provider business mailing address

1484 S PEMBROKE DR
SOUTH ELGIN IL
60177-2931
US

V. Phone/Fax

Practice location:
  • Phone: 847-382-1568
  • Fax: 847-382-1585
Mailing address:
  • Phone: 331-425-5072
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160.006528
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: