Healthcare Provider Details

I. General information

NPI: 1770905432
Provider Name (Legal Business Name): PRO SPORTS AND SPINAL REHAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12337 S ROUTE 59 UNIT 119
PLAINFIELD IL
60585-4625
US

IV. Provider business mailing address

12337 S ROUTE 59 UNIT 119
PLAINFIELD IL
60585-4625
US

V. Phone/Fax

Practice location:
  • Phone: 815-267-6263
  • Fax: 815-782-8549
Mailing address:
  • Phone: 815-267-6263
  • Fax: 815-782-8549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038011835
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070006640
License Number StateIL

VIII. Authorized Official

Name: MR. RANDAL CYBULSKI
Title or Position: OWNER
Credential: DC
Phone: 815-267-6263