Provider Demographics
NPI:1689628471
Name:YORKVILLE PHYSICAL THERAPY AND SPORTS MEDICINE CENTER, LLC
Entity Type:Organization
Organization Name:YORKVILLE PHYSICAL THERAPY AND SPORTS MEDICINE CENTER, LLC
Other - Org Name:ATLAS PHYSICAL THERAPY & SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:630-978-6218
Mailing Address - Street 1:728 E. VETERAN'S PKWY
Mailing Address - Street 2:SUITE 107
Mailing Address - City:YORKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60560-1095
Mailing Address - Country:US
Mailing Address - Phone:630-553-0349
Mailing Address - Fax:630-553-0439
Practice Address - Street 1:728 E VETERANS PARKWAY
Practice Address - Street 2:SUITE 107
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-1979
Practice Address - Country:US
Practice Address - Phone:630-553-0349
Practice Address - Fax:630-553-0439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207969Medicare PIN