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NPI Code Detail

MEDICARE: BON GAMIAO PACIS PT

MEDICARE: BON GAMIAO PACIS 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
1225100000XPhysical Therapist070.017680IL

General Provider Information

NPI Number : 1649535972
Entity Type Code : Individual
Provider Name (Legal Business Name) : BON GAMIAO PACIS PT
Provider Business Mailing Address
First Line : 6700 S OGLESBY AVE
Second Line : APT 1405
City : CHICAGO
State : IL
Zip : 60649-1301
Country : US
Telephone Number : 312-953-1175
Fax Number :
Provider Business Practice Location Address
First Line : 4314 S WABASH AVE
Second Line :
City : CHICAGO
State : IL
Zip : 60653-3119
Country : US
Telephone Number : 312-953-1175
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/12/2012
Last Update Date : 07/12/2012

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