Healthcare Provider Details

I. General information

NPI: 1053557264
Provider Name (Legal Business Name): GOODLIFE PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2008
Last Update Date: 08/01/2024
Certification Date: 08/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16517 106TH CT
ORLAND PARK IL
60467-4545
US

IV. Provider business mailing address

9730 S WESTERN AVE
EVERGREEN PARK IL
60805-2814
US

V. Phone/Fax

Practice location:
  • Phone: 708-966-4386
  • Fax: 708-966-4387
Mailing address:
  • Phone: 708-581-9700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-013727
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MIRAB MICKEY SHAH
Title or Position: PHYSICAL THERAPIST
Credential: PT
Phone: 708-966-4386