Healthcare Provider Details

I. General information

NPI: 1275775421
Provider Name (Legal Business Name): FUNCTIONAL HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2009
Last Update Date: 10/10/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

852 MADISON ST
OAK PARK IL
60302-4441
US

IV. Provider business mailing address

852 MADISON ST
OAK PARK IL
60302-4441
US

V. Phone/Fax

Practice location:
  • Phone: 708-445-3965
  • Fax: 708-445-1355
Mailing address:
  • Phone: 708-445-3965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number070013594
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RYAN C TODD
Title or Position: OWNER
Credential: PT, DPT
Phone: 708-445-3965