Provider Demographics
NPI:1346368347
Name:PENTAFIL PHYSICAL THERAPY SERVICE
Entity Type:Organization
Organization Name:PENTAFIL PHYSICAL THERAPY SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MISS
Authorized Official - First Name:OLYMPHIA
Authorized Official - Middle Name:ROLDAN
Authorized Official - Last Name:TESORO
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:630-527-6370
Mailing Address - Street 1:790 ROYAL SAINT GEORGE DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-8955
Mailing Address - Country:US
Mailing Address - Phone:630-527-6370
Mailing Address - Fax:630-527-6374
Practice Address - Street 1:790 ROYAL SAINT GEORGE DR
Practice Address - Street 2:SUITE 105
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-8955
Practice Address - Country:US
Practice Address - Phone:630-527-6370
Practice Address - Fax:630-527-6374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2215734OtherBLUE CROSS BLUE SHIELD
IL2215734OtherBLUE CROSS BLUE SHIELD