Provider Demographics
NPI:1649659079
Name:FRON, SAMUEL (PTA)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:FRON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1636 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-1439
Mailing Address - Country:US
Mailing Address - Phone:708-990-6912
Mailing Address - Fax:
Practice Address - Street 1:5905 W WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60644-2845
Practice Address - Country:US
Practice Address - Phone:773-261-7074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL160006460225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant