Healthcare Provider Details

I. General information

NPI: 1669657995
Provider Name (Legal Business Name): ALL SPORTS MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2008
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7850 S QUINCY ST
WILLOWBROOK IL
60527
US

IV. Provider business mailing address

2 SOUTH 239 RTE 59
WARRENVILLE IL
60555
US

V. Phone/Fax

Practice location:
  • Phone: 630-515-2701
  • Fax: 630-428-4305
Mailing address:
  • Phone: 630-515-2701
  • Fax: 630-428-4305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number038-009491
License Number StateIL

VIII. Authorized Official

Name: DR. TERRY JAMES SMITH
Title or Position: OWNER
Credential: D.C.
Phone: 630-640-9073