=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497395933
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENVISION CARE THERAPY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/13/2020
-----------------------------------------------------
Last Update Date | 04/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1535 LAKE COOK RD STE 306
-----------------------------------------------------
City | NORTHBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60062-1452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-805-9690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 912 PRAGUE AVE
-----------------------------------------------------
City | BUFFALO GROVE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60089-2877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-805-9690
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BLESSON VARGHESE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 224-522-6550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------