=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568782316
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BODY FIXX
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2010
-----------------------------------------------------
Last Update Date | 06/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1044 N WESTERN AVE
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60045-1282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-234-0404
-----------------------------------------------------
Fax | 847-234-1019
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1044 N WESTERN AVE
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60045-1282
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-234-0404
-----------------------------------------------------
Fax | 847-234-1019
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | MR. STEVEN DANIEL SMITH
-----------------------------------------------------
Credential | PT
-----------------------------------------------------
Telephone | 847-234-0404
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 070-011962
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------