Healthcare Provider Details

I. General information

NPI: 1588737969
Provider Name (Legal Business Name): RAVADEE INPHOM P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3512 GREENWOOD AVE
WILMETTE IL
60091-1010
US

IV. Provider business mailing address

3512 GREENWOOD AVE
WILMETTE IL
60091-1010
US

V. Phone/Fax

Practice location:
  • Phone: 847-251-1231
  • Fax: 847-251-1231
Mailing address:
  • Phone: 847-251-1231
  • Fax: 847-251-1231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: