Provider Demographics
NPI:1659942183
Name:-
Entity Type:Organization
Organization Name:-
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:W
Authorized Official - Last Name:EADEN
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:224-465-1479
Mailing Address - Street 1:2972 SHAMROCK CIR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60124-4354
Mailing Address - Country:US
Mailing Address - Phone:224-465-1479
Mailing Address - Fax:
Practice Address - Street 1:2972 SHAMROCK CIR
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60124-4354
Practice Address - Country:US
Practice Address - Phone:224-465-1479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-06
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy