Healthcare Provider Details

I. General information

NPI: 1023146701
Provider Name (Legal Business Name): GEOFFREY RD ILLINGWORTH PT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 08/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 ADAMS ST
WESTMINSTER VT
05158-9706
US

IV. Provider business mailing address

36 ADAMS ST
WESTMINSTER VT
05158-9706
US

V. Phone/Fax

Practice location:
  • Phone: 802-463-4725
  • Fax:
Mailing address:
  • Phone: 802-463-4725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number104-0000015
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number040-0002739
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: