Healthcare Provider Details

I. General information

NPI: 1215039003
Provider Name (Legal Business Name): JOHN EDWIN ALLEN RKT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 OAK KNOLL DR
LAKE VILLA IL
60046-8669
US

IV. Provider business mailing address

216 OAK KNOLL DR
LAKE VILLA IL
60046-8669
US

V. Phone/Fax

Practice location:
  • Phone: 847-356-0819
  • Fax:
Mailing address:
  • Phone: 847-356-0819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code226300000X
TaxonomyKinesiotherapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: