Provider Demographics
NPI:1619608809
Name:BLASCO-REYES, ALEXANDER J (DPT)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:J
Last Name:BLASCO-REYES
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2122 YORK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1925
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:1294 S ROUTE 12
Practice Address - Street 2:
Practice Address - City:FOX LAKE
Practice Address - State:IL
Practice Address - Zip Code:60020-1950
Practice Address - Country:US
Practice Address - Phone:847-973-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-026904225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist