Provider Demographics
NPI:1376375394
Name:CORE SPORT & PHYSICAL THERAPY PLLC
Entity type:Organization
Organization Name:CORE SPORT & PHYSICAL THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:FIDLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICAL THERAPIST
Authorized Official - Phone:773-510-6422
Mailing Address - Street 1:2940 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-2408
Mailing Address - Country:US
Mailing Address - Phone:708-422-0990
Mailing Address - Fax:
Practice Address - Street 1:10224 S KEDZIE AVE UNIT C
Practice Address - Street 2:
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-3735
Practice Address - Country:US
Practice Address - Phone:773-941-6132
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORE FITNESS & PHYSICAL THERAPY INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-19
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty