Provider Demographics
NPI:1275775421
Name:FUNCTIONAL HEALTH AND WELLNESS
Entity Type:Organization
Organization Name:FUNCTIONAL HEALTH AND WELLNESS
Other - Org Name:FYZICAL THERAPY AND BALANCE CENTER OF SOUTH OAK PARK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:TODD
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:708-445-3965
Mailing Address - Street 1:852 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-4441
Mailing Address - Country:US
Mailing Address - Phone:708-445-3965
Mailing Address - Fax:
Practice Address - Street 1:852 MADISON ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-4441
Practice Address - Country:US
Practice Address - Phone:708-445-3965
Practice Address - Fax:708-445-1355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X, 2251G0304X, 261QP2000X
IL0700135942251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatricsGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1916Medicare PIN