Provider Demographics
NPI:1063485258
Name:KLARKOWSKI, ADAM B (PT)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:B
Last Name:KLARKOWSKI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-6106
Practice Address - Street 1:1212 MEMORIAL DR
Practice Address - Street 2:STE 1
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-2247
Practice Address - Country:US
Practice Address - Phone:920-652-9554
Practice Address - Fax:920-652-9556
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5856225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400161724Medicare PIN