Healthcare Provider Details

I. General information

NPI: 1700103264
Provider Name (Legal Business Name): INTEGRATED PHYSICAL MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 03/01/2022
Certification Date: 03/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2499 E JOLIET HWY
NEW LENOX IL
60451-2592
US

IV. Provider business mailing address

2499 E JOLIET HWY
NEW LENOX IL
60451-2592
US

V. Phone/Fax

Practice location:
  • Phone: 815-717-8355
  • Fax: 815-717-8416
Mailing address:
  • Phone: 815-717-8355
  • Fax: 815-717-8416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038.010761
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. SCOTT JOSEPH KENNY
Title or Position: OWNER
Credential: DC
Phone: 815-717-8355