Provider Demographics
NPI:1811328461
Name:WATANACHAIYOT, TRAIRUD-JACK (DPT)
Entity type:Individual
Prefix:MR
First Name:TRAIRUD-JACK
Middle Name:
Last Name:WATANACHAIYOT
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 OAKMONT LN STE 600C
Mailing Address - Street 2:
Mailing Address - City:WESTMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60559-5548
Mailing Address - Country:US
Mailing Address - Phone:630-575-6200
Mailing Address - Fax:
Practice Address - Street 1:4700 GILBERT AVE STE 43A
Practice Address - Street 2:
Practice Address - City:WESTERN SPRINGS
Practice Address - State:IL
Practice Address - Zip Code:60558-1670
Practice Address - Country:US
Practice Address - Phone:708-783-1044
Practice Address - Fax:708-783-1048
Is Sole Proprietor?:No
Enumeration Date:2013-12-09
Last Update Date:2022-09-23
Deactivation Date:2022-06-02
Deactivation Code:
Reactivation Date:2022-09-23
Provider Licenses
StateLicense IDTaxonomies
NY29013225100000X
IL070-025183225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist