=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548781297
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILLINOIS THERAPEUTIC & WELLNESS CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 605 HALEY MEADOWS DR
-----------------------------------------------------
City | ROMEOVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60446-3942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-877-8277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 HALEY MEADOWS DR
-----------------------------------------------------
City | ROMEOVILLE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60446-3942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-877-8277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | HAIDI SORIANO
-----------------------------------------------------
Credential | PHYSICAL THERAPIST
-----------------------------------------------------
Telephone | 630-877-8277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------