Provider Demographics
NPI:1578961793
Name:WENTZEL SHORE CAPITAL, INC
Entity Type:Organization
Organization Name:WENTZEL SHORE CAPITAL, INC
Other - Org Name:1ST CHOICE PHYSICAL THERAPY, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ZORNOW
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:847-515-3366
Mailing Address - Street 1:10719 DUNDEE RD
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-9706
Mailing Address - Country:US
Mailing Address - Phone:847-515-3366
Mailing Address - Fax:847-515-3356
Practice Address - Street 1:10719 DUNDEE RD
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-9706
Practice Address - Country:US
Practice Address - Phone:847-515-3366
Practice Address - Fax:847-515-3356
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WENTZEL SHORE CAPITAL, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070006659225100000X
IL070008677225100000X
IL070006647225100000X
IL070008735225100000X
IL070020083225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211831OtherPTAN