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General NPI Number Information
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NPI Number | 1033718192
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Entity Type | Organization
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Legal Business Name | PRAIRIE RIDGE ORTHOPEDIC
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Dates
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Enumeration Date | 10/20/2020
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Last Update Date | 11/15/2022
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Provider Practice Location Address
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Address Line | 1750 E COLBORN CAMP LN
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City | NOBLE
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State | IL
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Zip | 62868-2348
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Country | US
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Telephone | 618-302-1703
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Fax |
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Provider Business Mailing Address
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Address Line | 1750 E COLBORN CAMP LN
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City | NOBLE
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State | IL
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Zip | 62868-2348
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Country | US
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Telephone | 618-302-1703
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | JODY HAZEL
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Credential | LMT
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Telephone | 618-302-1703
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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