=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780825455
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AXCESS PHYSICAL THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2009
-----------------------------------------------------
Last Update Date | 07/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 141 N SCHUYLER AVE
-----------------------------------------------------
City | KANKAKEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60901-3828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-614-2100
-----------------------------------------------------
Fax | 815-614-2101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 141 N SCHUYLER AVE
-----------------------------------------------------
City | KANKAKEE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60901-3828
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 815-614-2100
-----------------------------------------------------
Fax | 815-614-2101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. AARON W FUERST
-----------------------------------------------------
Credential | DPT
-----------------------------------------------------
Telephone | 815-549-6587
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 070012917
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------