Healthcare Provider Details

I. General information

NPI: 1902205180
Provider Name (Legal Business Name): SOUTHWEST PHYSICAL MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2014
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24014 W RENWICK RD SUITE 103
PLAINFIELD IL
60544-8708
US

IV. Provider business mailing address

PO BOX 10171
CHICAGO IL
60610-0171
US

V. Phone/Fax

Practice location:
  • Phone: 815-417-5777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. MARC J STRONGIN
Title or Position: PRESIDENT
Credential: DC
Phone: 815-417-5777