Basic Information
| Provider Information | |||||||||
| NPI: | 1225351216 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHALOM EX-IMPORT, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EAST MEETS WEST THERAPEUTICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3609 LEE AVE | ||||||||
| Address2: | |||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600315429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476728927 | ||||||||
| FaxNumber: | 8476726850 | ||||||||
| Practice Location | |||||||||
| Address1: | 1244 AMERICAN WAY | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600483936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475499595 | ||||||||
| FaxNumber: | 8475499596 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2010 | ||||||||
| LastUpdateDate: | 09/08/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PELAYO | ||||||||
| AuthorizedOfficialFirstName: | JOAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8476728927 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PT, DPT | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070.014694 | IL | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.