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General NPI Number Information
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NPI Number | 1841473014
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Entity Type | Organization
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Legal Business Name | MYOFASCIAL THERAPY CENTER AT ROCKFORD, LLC
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Dates
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Enumeration Date | 12/11/2007
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Last Update Date | 12/11/2007
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Provider Practice Location Address
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Address Line | 421 S MULFORD RD
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City | ROCKFORD
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State | IL
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Zip | 61108-3009
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Country | US
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Telephone | 815-399-5734
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Fax |
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Provider Business Mailing Address
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Address Line | 421 S MULFORD RD
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City | ROCKFORD
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State | IL
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Zip | 61108-3009
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Country | US
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Telephone | 815-399-5734
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Fax |
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Authorized Official
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Title or Position | PHYSICAL THERAPIST OWNER
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Name | MR. CARL MARK PATRNCHAK
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Credential | PT
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Telephone | 815-399-5734
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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 | 0700002325
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License Number State | IL
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