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NPI Code Detail

MEDICARE: MRS. BRENDA JOY LARSON PITTACORA PTA

MEDICARE: MRS. BRENDA JOY LARSON PITTACORA PTA
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 Therapist160001451IL

General Provider Information

NPI Number : 1760701791
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. BRENDA JOY LARSON PITTACORA PTA
Provider Business Mailing Address
First Line : 412 W 31ST ST
Second Line :
City : CHICAGO
State : IL
Zip : 60616-3116
Country : US
Telephone Number : 312-225-3119
Fax Number : 312-225-3219
Provider Business Practice Location Address
First Line : 412 W 31ST ST
Second Line :
City : CHICAGO
State : IL
Zip : 60616-3116
Country : US
Telephone Number : 312-225-3119
Fax Number : 312-225-3219
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/01/2010
Last Update Date : 06/01/2010

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