Provider Demographics
NPI:1811181191
Name:LIVING WELL PHYSICAL THERAPY INC
Entity type:Organization
Organization Name:LIVING WELL PHYSICAL THERAPY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:ZAGULA
Authorized Official - Suffix:
Authorized Official - Credentials:MPT
Authorized Official - Phone:847-651-4419
Mailing Address - Street 1:1026 WRENS GATE
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-1268
Mailing Address - Country:US
Mailing Address - Phone:847-651-4419
Mailing Address - Fax:
Practice Address - Street 1:450 N SEYMOUR AVE
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1835
Practice Address - Country:US
Practice Address - Phone:847-949-4262
Practice Address - Fax:847-949-8526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-30
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.0075362251X0800X, 2251X0800X
IL198.000967171100000X
IL8051242133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208547Medicare UPIN