Healthcare Provider Details

I. General information

NPI: 1861942377
Provider Name (Legal Business Name): ATHLETICO LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10020 PROFESSIONAL CENTER DRIVE
HAMBURG MI
48139-0799
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 810-893-7623
  • Fax: 810-893-7624
Mailing address:
  • Phone: 630-575-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUANA GRANADOS
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 630-575-1980