Healthcare Provider Details

I. General information

NPI: 1750540027
Provider Name (Legal Business Name): LIBILY LUKOSE PT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9745 SOUTH KARLOV AVE 307
OAKLAWN IL
60453
US

IV. Provider business mailing address

9745 S KARLOV AVE 307
OAK LAWN IL
60453-3389
US

V. Phone/Fax

Practice location:
  • Phone: 708-423-8869
  • Fax:
Mailing address:
  • Phone: 708-423-8867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070012382
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: