=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932598422
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOFFETT PHYSICAL THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/21/2015
-----------------------------------------------------
Last Update Date | 01/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2410 ALFT LN SUITE 100
-----------------------------------------------------
City | ELGIN
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60124-7843
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 224-535-9778
-----------------------------------------------------
Fax | 847-669-8211
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12531 REGENCY PKWY
-----------------------------------------------------
City | HUNTLEY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60142-6500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-659-1000
-----------------------------------------------------
Fax | 847-659-1012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | LORETTA QUINLAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 847-659-1000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------