Provider Demographics
NPI:1407398126
Name:FREE BODY PHYSICAL THERAPY PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:FREE BODY PHYSICAL THERAPY PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:GUILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:773-599-3393
Mailing Address - Street 1:5509 HARVARD TER
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-2753
Mailing Address - Country:US
Mailing Address - Phone:773-599-3393
Mailing Address - Fax:
Practice Address - Street 1:3132 W NORTH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-8415
Practice Address - Country:US
Practice Address - Phone:773-599-3393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-11
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070019810261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL070019810OtherLICENSE NUMBER