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General NPI Number Information
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NPI Number | 1841434636
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Entity Type | Organization
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Legal Business Name | INNOVATIVE PEDIATRIC THERAPY, INC.
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Dates
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Enumeration Date | 04/24/2009
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Last Update Date | 04/24/2009
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Provider Practice Location Address
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Address Line | 1908 N MOHAWK ST UNIT 22
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City | CHICAGO
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State | IL
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Zip | 60614-5220
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Country | US
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Telephone | 773-677-3758
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Fax | 312-787-3072
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Provider Business Mailing Address
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Address Line | 1908 N MOHAWK ST UNIT 22
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City | CHICAGO
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State | IL
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Zip | 60614-5220
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Country | US
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Telephone | 773-677-3758
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Fax | 312-787-3072
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | TODD M BRUECK
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Credential |
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Telephone | 773-332-0403
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 252Y00000X
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Taxonomy Name | Early Intervention Provider Agency
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License Number | 070.013401
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License Number State | IL
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