Provider Demographics
NPI:1811358849
Name:PHOENIX UNDERGROUND PHYSICAL THERAPY LLC
Entity type:Organization
Organization Name:PHOENIX UNDERGROUND PHYSICAL THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:608-217-6841
Mailing Address - Street 1:1142 W NORTH SHORE AVE APT 3N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-4640
Mailing Address - Country:US
Mailing Address - Phone:608-217-6841
Mailing Address - Fax:
Practice Address - Street 1:1142 W NORTH SHORE AVE APT 3N
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-4640
Practice Address - Country:US
Practice Address - Phone:608-217-6841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070018695261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy