=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861150070
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOURISH PHYSICAL THERAPY & WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2021
-----------------------------------------------------
Last Update Date | 12/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6886 N TONTY AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-1315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-533-7844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6886 N TONTY AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60646-1315
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-533-7844
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICAL THERAPIST
-----------------------------------------------------
Name | DR. MEGAN H DILLON
-----------------------------------------------------
Credential | DPT, PT, NCS
-----------------------------------------------------
Telephone | 847-533-7844
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------