Provider Demographics
NPI:1609010545
Name:A BIG BLAST PROJECT
Entity Type:Organization
Organization Name:A BIG BLAST PROJECT
Other - Org Name:A BIG BLAST, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PENZELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-650-8161
Mailing Address - Street 1:2210 LINNEMAN ST
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60025-4168
Mailing Address - Country:US
Mailing Address - Phone:847-650-8161
Mailing Address - Fax:
Practice Address - Street 1:2210 LINNEMAN ST
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60025-4168
Practice Address - Country:US
Practice Address - Phone:847-650-8161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-22
Last Update Date:2011-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy