Healthcare Provider Details

I. General information

NPI: 1538893367
Provider Name (Legal Business Name): FINE LINE PHYSIO PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2022
Last Update Date: 02/16/2023
Certification Date: 02/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 W DEVON AVE
PARK RIDGE IL
60068-4764
US

IV. Provider business mailing address

713 W DEVON AVE
PARK RIDGE IL
60068-4764
US

V. Phone/Fax

Practice location:
  • Phone: 708-612-3339
  • Fax:
Mailing address:
  • Phone: 708-612-3339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: IOANNIS DIMITRIOS ANASTOS
Title or Position: PRESIDENT
Credential: DPT
Phone: 708-612-3339