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General NPI Number Information
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NPI Number | 1700516820
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Entity Type | Organization
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Legal Business Name | FORM PHYSICAL THERAPY, LLC
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Dates
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Enumeration Date | 06/13/2022
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Last Update Date | 07/26/2023
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Provider Practice Location Address
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Address Line | 10356 ROOSEVELT RD
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City | WESTCHESTER
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State | IL
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Zip | 60154
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Country | US
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Telephone | 708-497-4600
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Fax | 708-497-4601
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Provider Business Mailing Address
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Address Line | 10356 ROOSEVELT RD
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City | WESTCHESTER
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State | IL
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Zip | 60154
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Country | US
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Telephone | 708-497-4600
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Fax | 708-497-4601
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Authorized Official
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Title or Position | OWNER
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Name | KEVIN ELAVIA
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Credential | DPT
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Telephone | 708-497-4600
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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 |
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License Number State |
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