=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396277240
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATHLETICO, LTD.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2017
-----------------------------------------------------
Last Update Date | 03/30/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 E 17TH ST
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47408-1590
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-668-1880
-----------------------------------------------------
Fax | 812-668-1881
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 ENTERPRISE DR
-----------------------------------------------------
City | OAK BROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60523-8813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-575-6250
-----------------------------------------------------
Fax | 630-575-7450
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF BILLING OPERATIONS
-----------------------------------------------------
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 | 060005437
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------