Healthcare Provider Details

I. General information

NPI: 1689628471
Provider Name (Legal Business Name): YORKVILLE PHYSICAL THERAPY AND SPORTS MEDICINE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 10/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 E VETERANS PARKWAY SUITE 107
YORKVILLE IL
60560-1979
US

IV. Provider business mailing address

728 E. VETERAN'S PKWY SUITE 107
YORKVILLE IL
60560-1095
US

V. Phone/Fax

Practice location:
  • Phone: 630-553-0349
  • Fax: 630-553-0439
Mailing address:
  • Phone: 630-553-0349
  • Fax: 630-553-0439

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHARLES CLARK
Title or Position: OWNER
Credential: P.T.
Phone: 630-978-6218