Healthcare Provider Details

I. General information

NPI: 1801294194
Provider Name (Legal Business Name): OAK PARK PHYSIOTHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2014
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6435 NORTH AVE
OAK PARK IL
60302-1013
US

IV. Provider business mailing address

6435 NORTH AVE
OAK PARK IL
60302-1013
US

V. Phone/Fax

Practice location:
  • Phone: 708-848-7766
  • Fax: 773-337-9106
Mailing address:
  • Phone: 708-848-7766
  • Fax: 773-337-9106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038007932
License Number StateIL

VIII. Authorized Official

Name: JOHN M HAGEN
Title or Position: OWNER
Credential: DC
Phone: 708-848-7766