Provider Demographics
NPI:1386828267
Name:SOUTHWEST PHYSICAL THERAPY AND REHABILIATION, LTD
Entity Type:Organization
Organization Name:SOUTHWEST PHYSICAL THERAPY AND REHABILIATION, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:VAIL
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:708-499-4497
Mailing Address - Street 1:111 W. JACKSON STREET
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1845
Mailing Address - Country:US
Mailing Address - Phone:815-941-7777
Mailing Address - Fax:
Practice Address - Street 1:111 W. JACKSON STREET
Practice Address - Street 2:
Practice Address - City:MORRIS
Practice Address - State:IL
Practice Address - Zip Code:60450-1845
Practice Address - Country:US
Practice Address - Phone:815-941-7777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060005170261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01618548OtherBCBS OF ILLINOIS
IL211953Medicare PIN