Provider Demographics
NPI:1619539053
Name:RAZALO, NICO MADJUS
Entity Type:Individual
Prefix:MR
First Name:NICO
Middle Name:MADJUS
Last Name:RAZALO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 N PARKSIDE AVE APT 1S
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-3355
Mailing Address - Country:US
Mailing Address - Phone:773-600-4257
Mailing Address - Fax:
Practice Address - Street 1:4405 N PARKSIDE AVE APT 1S
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-3355
Practice Address - Country:US
Practice Address - Phone:773-600-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-06
Last Update Date:2019-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL023420225100000X
IN05013119A225100000X
NY044272225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist