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NPI Code Detail

MEDICARE: CASEY KETELSEN DPT

MEDICARE: CASEY KETELSEN DPT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical Therapist070016508IL

General Provider Information

NPI Number : 1093971152
Entity Type Code : Individual
Provider Name (Legal Business Name) : CASEY KETELSEN DPT
Provider Business Mailing Address
First Line : PO BOX 362
Second Line : 2900 US HIGHWAY 12 SUITE J
City : SPRING GROVE
State : IL
Zip : 60081-0362
Country : US
Telephone Number : 815-675-0699
Fax Number : 815-675-0689
Provider Business Practice Location Address
First Line : 2900 N US HIGHWAY 12 STE J
Second Line :
City : SPRING GROVE
State : IL
Zip : 60081-8322
Country : US
Telephone Number : 815-675-0699
Fax Number : 815-675-0689
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/29/2008
Last Update Date : 07/29/2008

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