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General NPI Number Information
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NPI Number | 1881567212
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Entity Type | Individual
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Provider Name | EARL JUSTIN SUICO PTA
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Gender | Male
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Dates
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Enumeration Date | 09/23/2025
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Last Update Date | 09/23/2025
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Provider Practice Location Address
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Address Line | 901 BIESTERFIELD RD STE 308
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City | ELK GROVE VILLAGE
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State | IL
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Zip | 60007-7324
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Country | US
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Telephone | 847-437-9889
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Fax |
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Provider Business Mailing Address
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Address Line | 1461 W SUMMERDALE AVE APT 1B
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City | CHICAGO
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State | IL
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Zip | 60640-2149
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Country | US
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Telephone | 331-645-0936
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 160.006852
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License Number State | IL
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