MEDICARE: BREAULT PHYSICAL THERAPY PC

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	225100000X	Physical Therapist		IL

General Provider Information

NPI Number	:	1437266327
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BREAULT PHYSICAL THERAPY PC

Provider Business Mailing Address
First Line	:	1820 WINDSOR RD
Second Line	:	SUITE B
City	:	LOVES PARK
State	:	IL
Zip	:	61111-4271
Country	:	US
Telephone Number	:	815-986-4411
Fax Number	:	815-986-4414

Provider Business Practice Location Address
First Line	:	1820 WINDSOR RD
Second Line	:	SUITE B
City	:	LOVES PARK
State	:	IL
Zip	:	61111-4271
Country	:	US
Telephone Number	:	815-986-4411
Fax Number	:	815-986-4414

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. MARY ANN BREAULT
Credential	:	LPT
Telephone Number	:	815-986-4411

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	09/11/2007

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