Healthcare Provider Details

I. General information

NPI: 1609622158
Provider Name (Legal Business Name): MIDWEST PERFORMANCE REHAB, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2024
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7212 N PECATONICA RD
LEAF RIVER IL
61047-9402
US

IV. Provider business mailing address

7212 N PECATONICA RD
LEAF RIVER IL
61047-9402
US

V. Phone/Fax

Practice location:
  • Phone: 630-809-9838
  • Fax:
Mailing address:
  • Phone: 630-809-9838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS MICHAEL VANT
Title or Position: PRESIDENT
Credential: PT, DPT, ATC
Phone: 630-809-9838