Provider Demographics
NPI:1710107545
Name:CLOSE, JOHN (MSPT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CLOSE
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:WORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60482-0037
Mailing Address - Country:US
Mailing Address - Phone:773-284-0888
Mailing Address - Fax:773-284-0880
Practice Address - Street 1:5764 S ARCHER AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-1643
Practice Address - Country:US
Practice Address - Phone:773-284-0888
Practice Address - Fax:773-284-0880
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070012935225100000X
WAPT00009340225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist