Healthcare Provider Details

I. General information

NPI: 1760759260
Provider Name (Legal Business Name): IRVING BALLENA ROSAUPAN OTR/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2011
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 S ROSELLE RD
SCHAUMBURG IL
60193-3100
US

IV. Provider business mailing address

675 S ROSELLE RD
SCHAUMBURG IL
60193-3100
US

V. Phone/Fax

Practice location:
  • Phone: 847-352-5500
  • Fax:
Mailing address:
  • Phone: 847-352-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number056007816
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: