Provider Demographics
NPI:1982781316
Name:WAUCONDA PHYSICAL THERAPY, INC.
Entity Type:Organization
Organization Name:WAUCONDA PHYSICAL THERAPY, INC.
Other - Org Name:WAUCONDA WELLNESS CLINIC, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHARLENE
Authorized Official - Middle Name:D
Authorized Official - Last Name:MECCHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-487-0290
Mailing Address - Street 1:363 N MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:WAUCONDA
Mailing Address - State:IL
Mailing Address - Zip Code:60084-3036
Mailing Address - Country:US
Mailing Address - Phone:847-487-0290
Mailing Address - Fax:847-487-0492
Practice Address - Street 1:363 N MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:WAUCONDA
Practice Address - State:IL
Practice Address - Zip Code:60084-3036
Practice Address - Country:US
Practice Address - Phone:847-487-0290
Practice Address - Fax:847-487-0492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL535060Medicare UPIN