Provider Demographics
NPI:1154651149
Name:360 PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:360 PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICAL THERAPIST
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:D
Authorized Official - Last Name:WOLF
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:312-614-1349
Mailing Address - Street 1:564 W JACKSON BLVD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-5702
Mailing Address - Country:US
Mailing Address - Phone:312-614-1349
Mailing Address - Fax:312-526-3312
Practice Address - Street 1:564 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60661-5702
Practice Address - Country:US
Practice Address - Phone:312-614-1349
Practice Address - Fax:312-526-3312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-13
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070015710225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty