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General NPI Number Information
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NPI Number | 1386188589
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Entity Type | Organization
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Legal Business Name | MTN PROACTIVE REHAB, LTD.
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Dates
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Enumeration Date | 12/07/2016
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Last Update Date | 12/07/2016
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Provider Practice Location Address
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Address Line | 5614 S PULASKI RD
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City | CHICAGO
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State | IL
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Zip | 60629-4420
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Country | US
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Telephone | 773-716-9500
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Fax |
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Provider Business Mailing Address
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Address Line | 630 N FRANKLIN ST APT 801
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City | CHICAGO
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State | IL
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Zip | 60654-8353
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Country | US
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Telephone | 773-716-9500
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. PETER ANDREW THOMPSON
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Credential | D.C.
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Telephone | 773-716-9500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 038010385
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License Number State | IL
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