Healthcare Provider Details

I. General information

NPI: 1891611471
Provider Name (Legal Business Name): VIVIAN MARTINDALE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130A JAMES OTIS SMITH DR
WALNUT MS
38683
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 662-223-0064
  • Fax: 662-223-0074
Mailing address:
  • Phone: 630-575-1980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8195
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: