Provider Demographics
NPI:1568794113
Name:BURANICZ, JAKE (PTA)
Entity Type:Individual
Prefix:MR
First Name:JAKE
Middle Name:
Last Name:BURANICZ
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:395 RODENBURG RD.
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:IL
Mailing Address - Zip Code:60172
Mailing Address - Country:US
Mailing Address - Phone:847-274-9561
Mailing Address - Fax:224-588-3012
Practice Address - Street 1:395 RODENBURG RD.
Practice Address - Street 2:HOME HEALTH - TRAVEL
Practice Address - City:ROSELLE
Practice Address - State:IL
Practice Address - Zip Code:60172
Practice Address - Country:US
Practice Address - Phone:847-274-9561
Practice Address - Fax:224-588-3012
Is Sole Proprietor?:No
Enumeration Date:2010-02-08
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160.002627208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation