=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508051475
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PARK RIDGE PHYSICAL THERAPY CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2007
-----------------------------------------------------
Last Update Date | 01/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1416 CANFIELD RD
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-5536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-698-7627
-----------------------------------------------------
Fax | 847-698-1486
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1416 CANFIELD RD
-----------------------------------------------------
City | PARK RIDGE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60068-5536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-698-7627
-----------------------------------------------------
Fax | 847-698-1486
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/ DIRECTOR
-----------------------------------------------------
Name | MR. VINOD K MALHOTRA
-----------------------------------------------------
Credential | P.T.
-----------------------------------------------------
Telephone | 847-698-7627
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 070002690
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------