Healthcare Provider Details

I. General information

NPI: 1689408874
Provider Name (Legal Business Name): JOHN MIZWICKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2024
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 EXECUTIVE DR STE 250
WESTMONT IL
60559-6137
US

IV. Provider business mailing address

900 RAND RD STE 300
DES PLAINES IL
60016-2359
US

V. Phone/Fax

Practice location:
  • Phone: 630-655-8785
  • Fax: 630-655-2759
Mailing address:
  • Phone: 847-324-3976
  • Fax: 847-929-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-028387
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: