Healthcare Provider Details

I. General information

NPI: 1356582753
Provider Name (Legal Business Name): WILSON FLANCO LABIDEZ PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2009
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9416 SKOKIE BLVD
SKOKIE IL
60077-1311
US

IV. Provider business mailing address

9416 SKOKIE BLVD
SKOKIE IL
60077-1311
US

V. Phone/Fax

Practice location:
  • Phone: 847-673-4800
  • Fax: 847-673-9322
Mailing address:
  • Phone: 847-673-4800
  • Fax: 847-673-9322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.016225
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: