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General NPI Number Information
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NPI Number | 1639725104
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Entity Type | Organization
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Legal Business Name | WILDERNESS PERFORMANCE THERAPY & STRENGTH TRAINING, LLC.
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Dates
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Enumeration Date | 08/12/2019
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Last Update Date | 04/28/2020
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Provider Practice Location Address
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Address Line | 1823 NESS WAY
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City | MONTGOMERY
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State | IL
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Zip | 60538-4073
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Country | US
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Telephone | 309-287-2509
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Fax |
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Provider Business Mailing Address
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Address Line | 1823 NESS WAY
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City | MONTGOMERY
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State | IL
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Zip | 60538-4073
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Country | US
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Telephone | 309-287-2509
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JUSTIN WILHOIT
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Credential |
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Telephone | 312-884-1190
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2000X
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Taxonomy Name | Physical Therapy Clinic/Center
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License Number |
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License Number State |
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