=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518638402
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2021
-----------------------------------------------------
Last Update Date | 09/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1326 35TH ST
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53140-5200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-863-6694
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1326 35TH ST
-----------------------------------------------------
City | KENOSHA
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53140-5200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRACTITIONER
-----------------------------------------------------
Name | NICOLE GRACE YULE
-----------------------------------------------------
Credential | PT, DPT
-----------------------------------------------------
Telephone | 630-863-6694
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------