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General NPI Number Information
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NPI Number | 1639673130
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Entity Type | Organization
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Legal Business Name | INVICTUS SPORTS MEDICINE LLC
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Dates
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Enumeration Date | 03/20/2018
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Last Update Date | 04/14/2018
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Provider Practice Location Address
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Address Line | 28430 N BALLARD DR
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City | LAKE FOREST
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State | IL
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Zip | 60045-4508
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Country | US
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Telephone | 847-980-6826
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Fax |
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Provider Business Mailing Address
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Address Line | 1925 S OSPREY LN
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City | LIBERTYVILLE
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State | IL
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Zip | 60048-4873
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Country | US
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Telephone | 847-980-6826
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Fax |
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Authorized Official
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Title or Position | OWNER/PHYSICAL THERAPIST
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Name | DR. AMADOR AYALA III
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Credential | DPT
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Telephone | 847-980-6826
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 070-023307
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License Number State | IL
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