Provider Demographics
NPI:1720611510
Name:HINES, JEREMIAH R (PTA)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:R
Last Name:HINES
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 1:2600 COMPASS RD
Mailing Address - Street 2:
Mailing Address - City:GLENVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60026-8001
Mailing Address - Country:US
Mailing Address - Phone:877-787-3422
Mailing Address - Fax:847-441-4130
Practice Address - Street 1:2775 VILLAGE PT
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-0099
Practice Address - Country:US
Practice Address - Phone:219-304-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09004094A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant