=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235598012
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEAK PHYSICAL THERAPY CLINIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2016
-----------------------------------------------------
Last Update Date | 05/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 E GRAND RIVER AVE SUITE 102
-----------------------------------------------------
City | BRIGHTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48116-1551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-360-0806
-----------------------------------------------------
Fax | 844-809-2246
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 N PLAZA DR SUITE 706
-----------------------------------------------------
City | SCHAUMBURG
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60173-6021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-393-4501
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF REVENUE
-----------------------------------------------------
Name | CHRISTINE IGYARTO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-393-4691
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------