Healthcare Provider Details

I. General information

NPI: 1043261464
Provider Name (Legal Business Name): THOMAS L NELSON R.K.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 N WESTERN AVE SUITE C
LAKE FOREST IL
60045-1282
US

IV. Provider business mailing address

33278 N ALGONQUIN DR
WILDWOOD IL
60030-1901
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-0404
  • Fax:
Mailing address:
  • Phone: 847-223-4017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number1517
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: