MEDICARE: DR. CHRISTINE PONG PT, DPT, OCS

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	070017344	IL

General Provider Information

NPI Number	:	1689807505
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHRISTINE PONG PT, DPT, OCS

Provider Business Mailing Address
First Line	:	1397 MAIN ST STE A
Second Line	:
City	:	CRETE
State	:	IL
Zip	:	60417-2951
Country	:	US
Telephone Number	:	708-367-8050
Fax Number	:

Provider Business Practice Location Address
First Line	:	1397 MAIN ST
Second Line	:
City	:	CRETE
State	:	IL
Zip	:	60417-2951
Country	:	US
Telephone Number	:	708-367-8050
Fax Number	:

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

Provider Enumeration Date	:	08/26/2009
Last Update Date	:	03/17/2018

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