Provider Demographics
NPI:1760520217
Name:CZARNECKI, DAVID (PTA)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:CZARNECKI
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13114 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-2439
Mailing Address - Country:US
Mailing Address - Phone:708-824-0515
Mailing Address - Fax:708-824-0517
Practice Address - Street 1:13114 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-2439
Practice Address - Country:US
Practice Address - Phone:708-824-0515
Practice Address - Fax:708-824-0517
Is Sole Proprietor?:No
Enumeration Date:2007-02-04
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160000470225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL160000470OtherLICENSE