Provider Demographics
NPI:1770905432
Name:PRO SPORTS AND SPINAL REHAB
Entity type:Organization
Organization Name:PRO SPORTS AND SPINAL REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDAL
Authorized Official - Middle Name:
Authorized Official - Last Name:CYBULSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-267-6263
Mailing Address - Street 1:12337 S ROUTE 59
Mailing Address - Street 2:UNIT 119
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-4625
Mailing Address - Country:US
Mailing Address - Phone:815-267-6263
Mailing Address - Fax:815-782-8549
Practice Address - Street 1:12337 S ROUTE 59
Practice Address - Street 2:UNIT 119
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-4625
Practice Address - Country:US
Practice Address - Phone:815-267-6263
Practice Address - Fax:815-782-8549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070006640225100000X
IL038011835111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty