Provider Demographics
NPI:1770860124
Name:HEALTHY CONNECTION PHYSICAL MEDICINE INC
Entity type:Organization
Organization Name:HEALTHY CONNECTION PHYSICAL MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:
Authorized Official - Last Name:PUODZIUNAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-834-9075
Mailing Address - Street 1:16626 W 159TH ST
Mailing Address - Street 2:SUITE700
Mailing Address - City:LOCKPORT
Mailing Address - State:IL
Mailing Address - Zip Code:60441-8018
Mailing Address - Country:US
Mailing Address - Phone:815-834-9075
Mailing Address - Fax:815-834-9077
Practice Address - Street 1:16626 W 159TH ST
Practice Address - Street 2:SUITE700
Practice Address - City:LOCKPORT
Practice Address - State:IL
Practice Address - Zip Code:60441-8018
Practice Address - Country:US
Practice Address - Phone:815-834-9075
Practice Address - Fax:815-834-9077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036126664208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty