MEDICARE: SPOT 4 KIDS, INC.

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
1	261QP2000X	Physical Therapy Clinic/Center		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4520064	OTHER	IL	BCBS OF ILLINOIS

General Provider Information

NPI Number	:	1225157696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPOT 4 KIDS, INC.

Provider Business Mailing Address
First Line	:	29D STONEHILL RD
Second Line	:
City	:	OSWEGO
State	:	IL
Zip	:	60543-9449
Country	:	US
Telephone Number	:	630-554-6156
Fax Number	:	630-554-6378

Provider Business Practice Location Address
First Line	:	29D STONEHILL RD
Second Line	:
City	:	OSWEGO
State	:	IL
Zip	:	60543-9449
Country	:	US
Telephone Number	:	630-554-6156
Fax Number	:	630-554-6378

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. ELISABETH M. VANBOEKEL
Credential	:	PT
Telephone Number	:	630-554-6156

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	08/22/2020

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