MEDICARE: KIDS AT HEART PHYSICAL THERAPY, 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	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1396070884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS AT HEART PHYSICAL THERAPY, INC.

Provider Business Mailing Address
First Line	:	2215 W SHAKESPEARE AVE
Second Line	:	UNIT: COACH HOUSE
City	:	CHICAGO
State	:	IL
Zip	:	60647-3216
Country	:	US
Telephone Number	:	630-664-3445
Fax Number	:	630-994-5023

Provider Business Practice Location Address
First Line	:	2215 W SHAKESPEARE AVE
Second Line	:	UNIT: COACH HOUSE
City	:	CHICAGO
State	:	IL
Zip	:	60647-3216
Country	:	US
Telephone Number	:	630-664-3445
Fax Number	:	630-994-5023

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ROBYN WYZINSKI
Credential	:
Telephone Number	:	630-664-3445

Provider Enumeration Date	:	10/16/2009
Last Update Date	:	06/14/2012

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