MEDICARE: MRS. KRISTEN B KRUSE PT

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	:	1609984244
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRISTEN B KRUSE PT

Provider Business Mailing Address
First Line	:	500 PARK BLVD
Second Line	:	SUITE LL80C
City	:	ITASCA
State	:	IL
Zip	:	60143-3121
Country	:	US
Telephone Number	:	630-285-8007
Fax Number	:	630-285-8017

Provider Business Practice Location Address
First Line	:	1440 W NORTH AVE
Second Line	:	SUITE 202
City	:	MELROSE PARK
State	:	IL
Zip	:	60160-1422
Country	:	US
Telephone Number	:	708-865-8600
Fax Number	:	708-765-8661

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/25/2006
Last Update Date	:	07/08/2007

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