Healthcare Provider Details

I. General information

NPI: 1023520244
Provider Name (Legal Business Name): ATHLETICO, LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2017
Last Update Date: 10/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5601 W MONEE MANHATTAN RD STE 115
MONEE IL
60449-8866
US

IV. Provider business mailing address

625 ENTERPRISE DR
OAK BROOK IL
60523-8813
US

V. Phone/Fax

Practice location:
  • Phone: 708-314-7761
  • Fax: 708-314-7762
Mailing address:
  • Phone: 630-575-6250
  • Fax: 630-575-7450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number060005437
License Number StateIL

VIII. Authorized Official

Name: JUANA GRANADOS
Title or Position: CREDENTTIALING MANAGER
Credential:
Phone: 630-575-1980