MEDICARE: FREEFORM PHYSICAL THERAPY LLC

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

General Provider Information

NPI Number	:	1275152746
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FREEFORM PHYSICAL THERAPY LLC

Provider Business Mailing Address
First Line	:	2906 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2921
Country	:	US
Telephone Number	:	773-301-3735
Fax Number	:

Provider Business Practice Location Address
First Line	:	2906 W FULLERTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2921
Country	:	US
Telephone Number	:	773-301-3735
Fax Number	:

Authorized Official
Title or Position	:	PHYSICAL THERAPIST
Name	:	OMER AGUILAR
Credential	:
Telephone Number	:	773-301-3735

Provider Enumeration Date	:	04/14/2020
Last Update Date	:	05/19/2020

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