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General NPI Number Information
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NPI Number | 1114300654
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Entity Type | Organization
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Legal Business Name | REHAB AND SPORTS MED OUTFITTERS, INC
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Dates
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Enumeration Date | 07/01/2015
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Last Update Date | 07/01/2015
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Provider Practice Location Address
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Address Line | 312 MORGAN VALLEY DR
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City | OSWEGO
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State | IL
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Zip | 60543-8038
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Country | US
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Telephone | 630-383-9404
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Fax |
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Provider Business Mailing Address
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Address Line | 110 KIRKLAND CIR STE H
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City | OSWEGO
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State | IL
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Zip | 60543-8068
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Country | US
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Telephone | 630-383-9404
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. MARK P NASO
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Credential | O.T.
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Telephone | 630-383-9404
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 056005093
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License Number State | IL
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