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General NPI Number Information
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NPI Number | 1811358849
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Entity Type | Organization
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Legal Business Name | PHOENIX UNDERGROUND PHYSICAL THERAPY LLC
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Dates
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Enumeration Date | 03/18/2016
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Last Update Date | 03/18/2016
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Provider Practice Location Address
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Address Line | 1142 W NORTH SHORE AVE APT 3N
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City | CHICAGO
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State | IL
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Zip | 60626-4640
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Country | US
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Telephone | 608-217-6841
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Fax |
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Provider Business Mailing Address
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Address Line | 1142 W NORTH SHORE AVE APT 3N
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City | CHICAGO
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State | IL
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Zip | 60626-4640
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Country | US
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Telephone | 608-217-6841
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MATTHEW MCGUIRE
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Credential | DPT
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Telephone | 608-217-6841
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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 | 070018695
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License Number State | IL
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