Provider Demographics
NPI:1740717479
Name:MARAVILLA, STANISLAV C (MPT)
Entity type:Individual
Prefix:
First Name:STANISLAV
Middle Name:C
Last Name:MARAVILLA
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:2723 SHERIDAN RD
Practice Address - Street 2:SUITE D
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-2616
Practice Address - Country:US
Practice Address - Phone:847-794-4532
Practice Address - Fax:847-794-4533
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070007566225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist