Provider Demographics
NPI:1669652897
Name:SPRING GROVE PHYSICAL THERAPY LTD
Entity Type:Organization
Organization Name:SPRING GROVE PHYSICAL THERAPY LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:
Authorized Official - Last Name:DESTEPHANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-675-0675
Mailing Address - Street 1:2100 ROUTE 12
Mailing Address - Street 2:SUITE101
Mailing Address - City:SPRING GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60081
Mailing Address - Country:US
Mailing Address - Phone:815-675-0675
Mailing Address - Fax:
Practice Address - Street 1:2100 ROUTE 12
Practice Address - Street 2:SUITE101
Practice Address - City:SPRING GROVE
Practice Address - State:IL
Practice Address - Zip Code:60081
Practice Address - Country:US
Practice Address - Phone:815-675-0675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL042618917225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty