Provider Demographics
NPI:1922378447
Name:LTZ PHYSICAL THERAPY CENTER
Entity Type:Organization
Organization Name:LTZ PHYSICAL THERAPY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:MRS
Authorized Official - First Name:ZOSIMA
Authorized Official - Middle Name:ABIVA
Authorized Official - Last Name:VICTUELLES
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:630-890-7530
Mailing Address - Street 1:4117 W SHAMROCK LN
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-8289
Mailing Address - Country:US
Mailing Address - Phone:815-601-4613
Mailing Address - Fax:815-484-9226
Practice Address - Street 1:4117 W SHAMROCK LN
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-8289
Practice Address - Country:US
Practice Address - Phone:815-601-4613
Practice Address - Fax:815-484-9226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-01
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
IL041326250261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty