Healthcare Provider Details

I. General information

NPI: 1134485501
Provider Name (Legal Business Name): BRYNWOOD MYOFASCIAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6072 BRYNWOOD DR SUITE 102
ROCKFORD IL
61114-5829
US

IV. Provider business mailing address

6072 BRYNWOOD DR SUITE 102
ROCKFORD IL
61114-5829
US

V. Phone/Fax

Practice location:
  • Phone: 815-904-6163
  • Fax: 815-904-6516
Mailing address:
  • Phone: 815-904-6163
  • Fax: 815-904-6516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MALGORZATA ZASADNY
Title or Position: PHYSICAL THERAPIST/OWNER
Credential: PT
Phone: 815-904-6163