Provider Demographics
NPI:1013501477
Name:RELIVE PHYSICAL THERAPY INDIANA
Entity Type:Organization
Organization Name:RELIVE PHYSICAL THERAPY INDIANA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:JUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-903-3362
Mailing Address - Street 1:19070 EVERETT BLVD UNIT 206
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-2073
Mailing Address - Country:US
Mailing Address - Phone:708-790-3362
Mailing Address - Fax:
Practice Address - Street 1:11456 BROADWAY
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7106
Practice Address - Country:US
Practice Address - Phone:708-390-3362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-25
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN202102051459916OtherSTATE LICENSE
IN7083903362OtherPHONE