=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093013377
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FUNTASTIC INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2011
-----------------------------------------------------
Last Update Date | 03/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1020 CASTLEWOOD LN
-----------------------------------------------------
City | DEERFIELD
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60015-2646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-507-5960
-----------------------------------------------------
Fax | 847-986-4055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 373
-----------------------------------------------------
City | GRAYSLAKE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60030-0373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-507-5960
-----------------------------------------------------
Fax | 847-986-4055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | SHARON SILVERBERG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-507-5960
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QX0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------