Healthcare Provider Details

I. General information

NPI: 1851682363
Provider Name (Legal Business Name): OPAL THERAPY SERVICES LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2011
Last Update Date: 05/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7177 N LINCOLN AVE
LINCOLNWOOD IL
60712-2210
US

IV. Provider business mailing address

7177 N LINCOLN AVE
LINCOLNWOOD IL
60712-2210
US

V. Phone/Fax

Practice location:
  • Phone: 773-517-6489
  • Fax: 847-674-9888
Mailing address:
  • Phone: 773-517-6489
  • Fax: 847-674-9888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number070.007617
License Number StateIL

VIII. Authorized Official

Name: MS. ELIZABETH TONIDO
Title or Position: PROGRAM MANAGER
Credential: P.T.
Phone: 773-517-6489