Provider Demographics
NPI:1740406123
Name:WYLDE PHYSICAL THERAPY, LLC
Entity type:Organization
Organization Name:WYLDE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:WYLDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-264-8600
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:WATERMAN
Mailing Address - State:IL
Mailing Address - Zip Code:60556-0098
Mailing Address - Country:US
Mailing Address - Phone:815-264-8600
Mailing Address - Fax:331-431-5462
Practice Address - Street 1:125 N. CEDAR ST
Practice Address - Street 2:
Practice Address - City:WATERMAN
Practice Address - State:IL
Practice Address - Zip Code:60556
Practice Address - Country:US
Practice Address - Phone:815-264-8600
Practice Address - Fax:815-264-8644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700063622251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1932047OtherBCBS GROUP ID#
IL1932047OtherBCBS GROUP ID#