MEDICARE: AGATA M FOREMAN

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	225700000X	Massage Therapist	02.021803	IL

General Provider Information

NPI Number	:	1689292278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGATA M FOREMAN

Provider Business Mailing Address
First Line	:	6420 LAKEWOOD DR
Second Line	:
City	:	CARY
State	:	IL
Zip	:	60013-1239
Country	:	US
Telephone Number	:	224-704-9218
Fax Number	:

Provider Business Practice Location Address
First Line	:	333 COMMERCE DR STE 175
Second Line	:
City	:	CRYSTAL LAKE
State	:	IL
Zip	:	60014-3596
Country	:	US
Telephone Number	:	224-704-9218
Fax Number	:

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

Provider Enumeration Date	:	07/09/2020
Last Update Date	:	07/09/2020

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