MEDICARE: JERICO MONTANO 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	070015587	IL

General Provider Information

NPI Number	:	1932569852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERICO MONTANO PT

Provider Business Mailing Address
First Line	:	625 ENTERPRISE DR
Second Line	:
City	:	OAK BROOK
State	:	IL
Zip	:	60523-8813
Country	:	US
Telephone Number	:	630-575-6250
Fax Number	:	630-575-7450

Provider Business Practice Location Address
First Line	:	2620 N NARRAGANSETT AVE
Second Line	:	SUITE B7
City	:	CHICAGO
State	:	IL
Zip	:	60639-1081
Country	:	US
Telephone Number	:	773-237-7274
Fax Number	:	773-237-7302

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

Provider Enumeration Date	:	03/04/2016
Last Update Date	:	12/13/2016

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