Provider Demographics
NPI:1730109596
Name:NEW LIFE PHYSICAL THERAPY AND REHABILITATION P.C.
Entity Type:Organization
Organization Name:NEW LIFE PHYSICAL THERAPY AND REHABILITATION P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:KOOYENGA
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:708-774-2970
Mailing Address - Street 1:PO BOX 379
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-0379
Mailing Address - Country:US
Mailing Address - Phone:708-774-2970
Mailing Address - Fax:708-460-1117
Practice Address - Street 1:25622 S GOVERNORS HWY
Practice Address - Street 2:
Practice Address - City:MONEE
Practice Address - State:IL
Practice Address - Zip Code:60449-8987
Practice Address - Country:US
Practice Address - Phone:708-235-0144
Practice Address - Fax:708-235-0145
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2007-10-24
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
IL09932272OtherBCBS IL
IL09932272OtherBCBS IL