Provider Demographics
NPI:1134466162
Name:PURE HEALTH PHYSICAL MEDICINE, LLC
Entity Type:Organization
Organization Name:PURE HEALTH PHYSICAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:630-897-1895
Mailing Address - Street 1:2116 W GALENA BLVD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-3533
Mailing Address - Country:US
Mailing Address - Phone:630-897-1895
Mailing Address - Fax:
Practice Address - Street 1:2116 W GALENA BLVD
Practice Address - Street 2:SUITE 112
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-3533
Practice Address - Country:US
Practice Address - Phone:630-897-1895
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-10
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008765111N00000X
IL038011191111N00000X
IL038011696111N00000X
IL036099986207Q00000X
IL209010369363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL8252OtherMEDICARE PTAN