Provider Demographics
NPI:1689428021
Name:MATT AMBROSE LLC
Entity Type:Organization
Organization Name:MATT AMBROSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBROSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-269-1630
Mailing Address - Street 1:1016 W LAKE ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-1715
Mailing Address - Country:US
Mailing Address - Phone:630-269-1630
Mailing Address - Fax:
Practice Address - Street 1:1016 W LAKE ST UNIT 2
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-1715
Practice Address - Country:US
Practice Address - Phone:630-269-1630
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-12
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy