Healthcare Provider Details

I. General information

NPI: 1568782316
Provider Name (Legal Business Name): BODY FIXX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 06/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1044 N WESTERN AVE
LAKE FOREST IL
60045-1282
US

IV. Provider business mailing address

1044 N WESTERN AVE
LAKE FOREST IL
60045-1282
US

V. Phone/Fax

Practice location:
  • Phone: 847-234-0404
  • Fax: 847-234-1019
Mailing address:
  • Phone: 847-234-0404
  • Fax: 847-234-1019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number070-011962
License Number StateIL

VIII. Authorized Official

Name: MR. STEVEN DANIEL SMITH
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 847-234-0404