Provider Demographics
NPI:1023430691
Name:TAMBAGO, SAMUEL ALMOGUERA JR (DPT)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ALMOGUERA
Last Name:TAMBAGO
Suffix:JR
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2224 MISTY CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-5047
Mailing Address - Country:US
Mailing Address - Phone:714-417-6155
Mailing Address - Fax:
Practice Address - Street 1:2224 MISTY CREEK TRL
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-5047
Practice Address - Country:US
Practice Address - Phone:714-417-6155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070016190225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0307161979Medicaid
IL0307161979Medicaid
0307161979Medicare PIN
0307161979Medicare UPIN
0307161979Medicare Oscar/Certification