Provider Demographics
NPI:1487639423
Name:PHYSICAL THERAPY CENTER LTD
Entity Type:Organization
Organization Name:PHYSICAL THERAPY CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PT
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LANDREBE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:815-935-8782
Mailing Address - Street 1:1230 N CONVENT ST
Mailing Address - Street 2:A
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1006
Mailing Address - Country:US
Mailing Address - Phone:815-935-8782
Mailing Address - Fax:815-835-8799
Practice Address - Street 1:1230 N CONVENT ST
Practice Address - Street 2:A
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1006
Practice Address - Country:US
Practice Address - Phone:815-935-8782
Practice Address - Fax:815-835-8799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-13
Last Update Date:2012-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL060005773225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL326690Medicare ID - Type Unspecified