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General NPI Number Information
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NPI Number | 1811212988
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Entity Type | Organization
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Legal Business Name | BODY AND WELLNESS PHYSICAL THERAPY, LLC
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Dates
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Enumeration Date | 04/01/2010
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Last Update Date | 04/01/2010
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Provider Practice Location Address
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Address Line | 2500 RIDGE AVE STE 309
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City | EVANSTON
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State | IL
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Zip | 60201-2477
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Country | US
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Telephone | 312-961-9490
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Fax |
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Provider Business Mailing Address
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Address Line | 1136 W FULLERTON AVE APT 2
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City | CHICAGO
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State | IL
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Zip | 60614-8159
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Country | US
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Telephone | 312-961-9490
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Fax |
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Authorized Official
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Title or Position | DPT
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Name | REBECCA LANDIS
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Credential | PT
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Telephone | 312-961-9490
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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 | 070013544
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License Number State | IL
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