Provider Demographics
NPI:1639715949
Name:GOOSEBERRY INC.
Entity Type:Organization
Organization Name:GOOSEBERRY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GENE
Authorized Official - Middle Name:
Authorized Official - Last Name:KRUHLY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DPT
Authorized Official - Phone:224-836-0121
Mailing Address - Street 1:5632 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:CLARENDON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60514-1517
Mailing Address - Country:US
Mailing Address - Phone:224-832-0121
Mailing Address - Fax:
Practice Address - Street 1:5632 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:CLARENDON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60514-1517
Practice Address - Country:US
Practice Address - Phone:224-832-0121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-21
Last Update Date:2019-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation