Healthcare Provider Details

I. General information

NPI: 1609324821
Provider Name (Legal Business Name): NICHOLAS FENDT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9000 WAUKEGAN RD STE 100
MORTON GROVE IL
60053-2128
US

IV. Provider business mailing address

900 RAND RD SUITE 300
DES PLAINES IL
60016-2359
US

V. Phone/Fax

Practice location:
  • Phone: 847-779-6050
  • Fax: 847-929-1167
Mailing address:
  • Phone: 847-324-3976
  • Fax: 847-929-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-022434
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: