Provider Demographics
NPI:1093003451
Name:CALVADORES, JUAN CARLO CAPIRAL (OT)
Entity Type:Individual
Prefix:MR
First Name:JUAN CARLO
Middle Name:CAPIRAL
Last Name:CALVADORES
Suffix:
Gender:M
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5946 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-5424
Mailing Address - Country:US
Mailing Address - Phone:773-775-6637
Mailing Address - Fax:773-775-6638
Practice Address - Street 1:5946 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-5424
Practice Address - Country:US
Practice Address - Phone:773-775-6637
Practice Address - Fax:773-775-6638
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-008637225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056-008637OtherLICENSE NUMBER