=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164841300
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATHLETICO LTD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2014
-----------------------------------------------------
Last Update Date | 07/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440 E ROOSEVELT RD SUITE 104
-----------------------------------------------------
City | WEST CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60185-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-293-5300
-----------------------------------------------------
Fax | 630-293-9800
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 E ROOSEVELT RD SUITE 104
-----------------------------------------------------
City | WEST CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60185-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-293-5300
-----------------------------------------------------
Fax | 630-293-9800
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CLINICAL SERVICES
-----------------------------------------------------
Name | GERI COOK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-575-1940
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------