Healthcare Provider Details

I. General information

NPI: 1356366082
Provider Name (Legal Business Name): CARL GUSTAFSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 06/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 LAUREL AVE
WELLESLEY MA
02481-7523
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440
US

V. Phone/Fax

Practice location:
  • Phone: 781-237-5585
  • Fax: 781-237-5633
Mailing address:
  • Phone: 630-296-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LYNN MCGIVERN
Title or Position: CHIEF COMPLIANCE OFFICER
Credential:
Phone: 630-296-2222