Provider Demographics
NPI:1093026643
Name:KOPACZ, CHRISTOPHER J (PTA)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:J
Last Name:KOPACZ
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1240 ESSINGTON RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-8426
Mailing Address - Country:US
Mailing Address - Phone:815-744-7108
Mailing Address - Fax:815-744-7057
Practice Address - Street 1:1240 ESSINGTON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-8426
Practice Address - Country:US
Practice Address - Phone:815-744-7108
Practice Address - Fax:815-744-7057
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2010-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.004282225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL213760Medicare PIN