Healthcare Provider Details

I. General information

NPI: 1174959340
Provider Name (Legal Business Name): FAMILY PHYSICAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 N MAIN ST
PORT BYRON IL
61275-7705
US

IV. Provider business mailing address

P.O. BOX 125 103 NORTH MAIN STREET
PORT BYRON IL
61275-7703
US

V. Phone/Fax

Practice location:
  • Phone: 309-523-2949
  • Fax:
Mailing address:
  • Phone: 309-523-2949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070006904
License Number StateIL

VIII. Authorized Official

Name: MR. ROBERT STANLEY JOHANNSEN
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: PT
Phone: 309-523-2949