Provider Demographics
NPI:1639914476
Name:PRISM PHYSICAL THERAPY & PERFORMANCE TRAINING PLLC
Entity type:Organization
Organization Name:PRISM PHYSICAL THERAPY & PERFORMANCE TRAINING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:LEISE
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:630-730-7003
Mailing Address - Street 1:15164 S GINGER LN
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-5643
Mailing Address - Country:US
Mailing Address - Phone:630-730-7003
Mailing Address - Fax:
Practice Address - Street 1:24520 S US ROUTE 52
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:IL
Practice Address - Zip Code:60442
Practice Address - Country:US
Practice Address - Phone:630-730-7003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy