Healthcare Provider Details

I. General information

NPI: 1053621607
Provider Name (Legal Business Name): LEGACY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2010
Last Update Date: 10/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 SOUTH HI LUSI AVE
MOUNT PROSPECT IL
60056
US

IV. Provider business mailing address

120 SOUTH HI LUSI AVE
MOUNT PROSPECT IL
60056
US

V. Phone/Fax

Practice location:
  • Phone: 847-670-7214
  • Fax:
Mailing address:
  • Phone: 847-670-7214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number160.002590
License Number StateIL

VIII. Authorized Official

Name: MR. PARVIZ AYREMPOUR
Title or Position: PHYSICAL THERAPIST ASSISTANT
Credential: PTA
Phone: 847-670-7214