Healthcare Provider Details

I. General information

NPI: 1669701553
Provider Name (Legal Business Name): KRISTINE MAE MARTINEZ BANAS RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2009
Last Update Date: 12/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10700 W HIGGINS RD SUITE 120
ROSEMONT IL
60018-3707
US

IV. Provider business mailing address

4945 N NAGLE AVE
CHICAGO IL
60630-2927
US

V. Phone/Fax

Practice location:
  • Phone: 847-299-2801
  • Fax:
Mailing address:
  • Phone: 773-681-6142
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.017019
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: