Provider Demographics
NPI:1639673130
Name:INVICTUS SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:INVICTUS SPORTS MEDICINE LLC
Other - Org Name:INVICTUS SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMADOR
Authorized Official - Middle Name:
Authorized Official - Last Name:AYALA
Authorized Official - Suffix:III
Authorized Official - Credentials:DPT
Authorized Official - Phone:847-980-6826
Mailing Address - Street 1:1925 S OSPREY LN
Mailing Address - Street 2:
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-4873
Mailing Address - Country:US
Mailing Address - Phone:847-980-6826
Mailing Address - Fax:
Practice Address - Street 1:28430 N BALLARD DR
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:IL
Practice Address - Zip Code:60045-4508
Practice Address - Country:US
Practice Address - Phone:847-980-6826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2018-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070-023307225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty