Provider Demographics
NPI:1053506451
Name:GIVEN SPORTS & PHYSICAL THERAPY, P.C.
Entity Type:Organization
Organization Name:GIVEN SPORTS & PHYSICAL THERAPY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:GIVEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, MHS, SCS, ATC
Authorized Official - Phone:815-477-8004
Mailing Address - Street 1:540 E TERRA COTTA AVE
Mailing Address - Street 2:SUITE G
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3652
Mailing Address - Country:US
Mailing Address - Phone:815-477-8004
Mailing Address - Fax:815-477-8005
Practice Address - Street 1:540 E TERRA COTTA AVE
Practice Address - Street 2:SUITE G
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3652
Practice Address - Country:US
Practice Address - Phone:815-477-8004
Practice Address - Fax:815-477-8005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL215872OtherPTAN